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LEPROSY NEWS AND NOTES Information concerning institutions, organizations, and indi

viduals connected with leprosy work, scientific or other meetings, legislative enactments and other matters of interest.

( FIFTH INTERNATIONAL LEPROSY CONGRESS SPONSORED BY THE GOVERNMENT OF THE REPUBLIC

OF CUBA AND THE INTERNATIONAL LEPROSY ASSOCIATION

HELD IN HAVANA, APRIL 3 TO 11, 1948

Honorary President Dr. Ram6n Grau San Martin

President of the Republic

Honorary Jfembers Dr. Raul Lopez del Castillo, Prime Minister of the Republic, Dr. Rafael Gonzalez Munoz, Minister of State, Dr. Ramiro de la Riva, Minister of Health and Social Welfare, Dr. Alberto Cruz, Minister of Communications, Dr. Rafael Guas Inclan, Governor of Havana Province, Mr. Nicolas Castellanos, Mayor of the City of Havana, Professor Clemente Inclan, Rector of the Universi,ty of Havana, Professor Angel Vieta Barahona, Dean of the Faculty of Medi-

cine, University of Havana, Professor Antonio Valdes Dapena, President of the Board of

Governors, Foundation for the Profilaxis of Syphilis, Leprosy and Cutaneous Diseases,

Professor Dr. Braulio Saenz Ricart, Professor of Dermatology, University of Havana,

Professor Dr. Vicente Pardo Castello, Assistant Professor of Dermatology, University of Havana.

NATIONAL ORGANIZING COMMITTEE

Chairman: Dr. Alberto Oteiza Setien. Secretary: Dr. Ismael Ferrer Pulgaron. Treasurer: Dr. Braulio Saenz. Assistant Secretaries: Dr. Luis Rodriguez Plasencia, Dr. Ovidio

Laosa, Dr. Adolfo Garcia Miranda. Jfembers: Dr. Luis Espinosa, Dr. Guillermo Sowers, Dr. Fran

cisco R. Tiant, Dr. Francisco M. Condom, Dr. Jorge Pina, Dr. Guillermo Gonzalez Peris, Dr. Jose Castro Palomino, Dr. Juan Jose Mestre, Dr. Conrado Valhuerdi, Dr. Fernando Trespalacios, Dr. Ramon Ibarra Perez, Dr. Miguel Angel Gonzalez Prendes, and Dr. Pastor Farinas.

187

188 International Journal of Leprosy

INTERNATIONAL LEPROSY ASSOCIATION

President: Dr:H. W. Wade. Vice-Presidents: Dr. P. Baliiia and Dr. John Lowe. General Secretary-Treasurer: Dr. E. Muir.

1948

Councillors: Dr. E. Burnet, Dr. V. Heiser, Dr. P. Lampe, Dr. B. Moiser, Dr. M. Ota, Dr. J. N. Rodriguez, Sir Leonard Rogers, Dr. G. Ryrie, Dr. N. Serra, Dr. F. Sorel, Dr. Alberto Oteiza, Dr. Robert Cochrane.

ORGANIZATION OF THE CONGRESS

Congress Council.-After the arrival of representatives of the International Leprosy Association, there was set up a Congress Council mainly to deal with matters relating to the sessions. This Council consisted of The National Organizing Committee and the officers and members of the Councils of the International Leprosy Association attending the Congress.

Executive Committee.-The Congress Council created an Executive Committee, consisting of Drs. Oteiza and Ferrer, respectively Chairman and Secretary of the Organizing Committee, and Drs. Wade and Muir, respectively President and General Secretary-Treasurer of the Association. To this group were added later, by action taken at the Inaugural Session, Drs. Quiroga, Agricola and Gay Prieto.

Scientific Program Committee.-Specifically to be responsible for preparing the programs of the scientific sessions, the Congress Council created a committee consisting of Drs. Muir, Wade and Ferrer, the last of whom designated Dr. Rodriguez Plasencia as his representative.

The principal matters considered by the Council as so organized, at a meeting held on Friday, April 2nd, were the special scientific committees which should be set up and their membership, and the program of the scientific sessions. The latter matter constituted a real problem for the reason that many more papers had been offered than could be read, within the time available, in a meeting of the whole. This was true of those received before the "dead-line" date of March 25th; the matter was complicated by the fact that some of those received later than that date were eligible for inclusion because they had been mailed in good time, to say nothing of the fact that several members came with papers which they expected to read though they had not submitted titles and abstracts beforehand. It was agreed that it would be highly undesirable to schedule over-flow sections in a smaller room, simultaneously with the main sessions

16,2 Leprosy N ews and Notes 189

in the auditorium. To avoid that contingency the following rules were adopted and posted.

(1) The time limit for each paper would be 10 minutes (instead of 15 minutes as originally intended), that limit to be strictly observed and to include the time required for lantern-slide or other demonstrations. Papers would, so far as possible, be arranged in related groups, and discussion periods would be provided for, afteF groups instead of after individual papers. Participants in discussions would be limited to two minutes each.

(2) Papers might be read only by the author, or one of the authors, in person. Papers submitted by persons not present would be "read by title."

(3) No paper might be read which had already been published. (4) No member of the Congress might read more than two papers;

those submitted in excess of that number would be read by title.

PROGRAM OF THE CONGRESS

SATURDAY, APRIL 3, 1948

Registration of delegates and other members, at the Congress hall, the Escuela Municipal Valdez Rodriguez (beginning 9 a. m.).

Presentation to the Honorable, the President of the Republic, at the Presidential Palace (noon).

Reception by the Minister of Public Health and Social Welfare; buffet; at the National Capitol (6 p. m.).

SUNDAY, APRIL 4, 1948

Tour of the city, visiting points of historical and other interest (forenoon).

Formal Opening Session, the President of the Republic presiding, in the Chamber of the House of Representatives, National Capitol (9 p. m.). Addresses by the Chairman of the Organizing Committee (Dr. Oteiza), the President of the International Leprosy Association (Dr. Wade), and by representatives of four linguistic groups: English (Dr. Muir), French (Dr. Chaussinand), Portuguese (Dr. Agricola), and Spanish (Dr. Llano). The final and principal address was by President Grau San Martin.

MONDAY, APRIL 5, 1948

Inaugural Plena1'Y Session (9 a. m.)-(See minutes later.) First scientific session (10 a. m.)-Dr. A. Oteiza, Chairman;

Dr. L. M. Bechelli, Secretary. Sulfone therapy. Second scientific session (3 p. m.)-Dr. H. W. Wade, Chair

man; Dr. F. R. Tiant, Secretary. Sulfone therapy (continued). Social event (6 p. m.) ~Tea party, by the Lyceum and Lawn

Tennis Club, arranged by the Ladies Committee.

190 International Journal of Leprosy 1948

TUESDAY, APRIL 6, 1948

Third scientific session (9 a. m.)-Dr. M. H. Soule, Chairman; Dr. C. B. Lara, Secretary. Therapy (contd.) other forms.

Fourth scientific session (3 p. m.)-Dr. R. G. Cochrane, Chairman; Dr. E. Koppisch, S ecretary. Clinical features, various.

Social event (6 p. m. ) -Tea offered by the Sociedad Cubana de Dermatologia y Siphilografia, at the Club de Profesionales de Cuba.

WEDNESDAY, APRIL 7, 1948

Fifth scientific session (9 a. m.) -Prof. Braulio Saenz, Chairman; Dr. C. J. Austin, Secretary. Clinical features (contd.), diagnostic procedures; classification.

Sixth scientific session (3 p. m.) -Prof. Gougerot, Chairman; Dr. M. Vegas, Secretary. Bacteriology and pathology.

Social event (6 p. m.) -Cocktail party, by the Colegio Medico Nacional.

THURSDAY, APRIL 8, 1948

Seventh scientific session (9 a. m.) -Dr. M. Dalgamouni, Chairman; Dr. A. R. Davison, Secretary. Blood chemistry, serology and immunology.

Social event-Country luncheon, tendered by the Governor of the Province of Havana and the Council of Mayors of the Province, at the Rio Cristal Restaurant.

Afternoon-Visit to the San Lazaro Hospital at Rincon, near Havana.

Evening (10 p. m.)-"Noche de Musica Cubana," at the Radio Center.

FRIDAY, APRIL 9, 1948

Eighth scientific session (9 a. m.)-Dr. F. A. Rabello, Chairman; Dr. N. D. Fraser, Secretary. Epidemiology, distribution and control, etc.

Social event-Luncheon for the ladies of the Congress and of Congress members, by the Ladies Committee, at the Havana Yacht Club.

Ninth scientific session (3 p. m.)-Sir Walter Kinnear, Chairman; Mrs. Eunice Weaver, Secretary. Epidemiology (contd.), principles; Social Welfare.

Film session-After the scientific session adjourned there was an exhibit, in the library room, of a film on Makogai.

Social event-Reception by the Mayor of Havana, at the Municipal Palace.

16,2 Leprosy News and Notes ~91

SATURDAY, APRIL 10, 1948

Picnic at Varadero Beach; lunch at the Kawama Yacht Club.

SUNDAY. APRIL 11. 1948

Closing plenary session (9 a. m.)-(See minutes, later.) Meeting of the International Leprosy Association. Social event-Banquet offered by the Minister of State, at

the Vedado Tennis Club. Addresses by the Minister of State, the President of the International Leprosy Association, and Dr. Gay Prieto representing the Congress as a whole.

MEMBERS OF THE CONGRESS

The following list of members, totalling 226, was compiled by the secretariat after the close of the Congress. The host country contributed an exceptional number, no less than 80; those from abroad totaled 143. The list includes several persons who are not concerned with leprosy work but who took advantage of the privileges out of general interest or for other reasons. It does not include the ladies, not entitled under the rules to join as members, nor a few other persons who paid the fee set for the privilege of the social events.

Agricola, Dr. Ernani, Rio de Janeiro, Brazil. Official. de Aguiar Pupo, Dr. JOllO, Sao Paulo, Brazil. Institutional. Aleixo, Dr. Josephino, Belo Horizonte, Brazil. Institutional. d'Alessandro, Dr. Miguel A., Santiago de Cuba. Institutional. Alfonso Armenteros, Dr. Jose, Marianao, Cuba. Institutional. Alonso Perez, Dr. Manuel, Havana, Cuba. Institutional. Aller Atucha, Dr. Juan F., Buenos Aires, Argentina. Official .. Ambles Pipo, Dr. Manuel, Spain. Official. Angulo, Dr. Jose Manuel, Havana, Cuba. Institutional. Arguelles Casals, Dr. Dario, Havana, Cuba. Institutional. Arias, Dr. Oswaldo, Mexico. Institutional. Arnold, Dr. Harry L., Honolulu, T. H., U. S. A. Institutional. Austin, Dr. C. J., Makogai, Fiji. Private.

Bafion, Dr. Pedro, Tucuman, Argentina. Institutional. Barba Rubio, Dr. Jose, Guadalajara, Jal., Mexico. Institutional. Basombrio, Dr. Guillermo, Buenos Aires, Argentina. Official. Beade Millet, Dr. Pedro, Havana, Cuba. Institutional. Bechelli, Dr. Luis Marino, Sao Paulo, Brazil. Official. Bishop, Mr. Francis, Rochester, N. Y., U. S. A. Institutional. Borrell Navarro, Dr. Edwardo, Havana, Cuba. Private. Braga, Dr. Renato Pacheco, Sao Paulo, Brazil. Official. Brownlee, Dr. George, London, England. Institutional. Bulle Merry, Dr. Adolfo, Havana, Cuba. Institutional. Burgess, Mr. Perry, New York, N. Y., U. S. A. Institutional. Burgess, Mrs. Cora Turney, New York., U. S. A. Institutional. Busto, Dr. Jose Manuel, Havana, Cuba. Institutional.

/ 192 International Journal of Leprosy 948

Calvo Fonseca, Dr. Rafael, Havana, Cuba. Institutional. Campbell, Dr. George, Chacachacare, Trinidad, B. W. I. Institutional. Canizares, Dr. Orlando, New York, N. Y., U. S. A. Institutional. Capurro, Dr. Ernesto Tomas, Buenos Aires, Argentina. Official. Carpenter, Dr. Charles M., Los Angeles, Calif., U. S. A. Institutional. Cardenal de Salas, Dr. Carlos, Barcelona, Spain. Institutional. Castanedo, Dr. Carlos, Marianao, Cuba. Institutional. Castellani, Dr. Aldo, Lisbon, Portugal. Institutional. Castellanos S., Dr. Rene M., Havana, Cuba. Institutional. Castro Palomino, Dr. Jose, Havana, Cuba. Official. Castro Flores, Dr. Virgilio, Mexico. Institutional. Cerruti, Dr. Humberto, Sao Paulo, S. P., Brazil. Institutional. Chaussinand, Dr. R., Paris, France. Official. Chevezz, Dr. Agustin, Mexico, D. F., Mexico. Institutional. Clavero del Campo, Dr. Gerardo, Madrid, Spain. Official. Cochrane, Dr. Robert G., Madras, India. Official. Cohen, Dr. Adele, Newark, N. J., U. S. A. Institutional. Cole, Dr. Howard 1., Washington, D. C., U. S. A. Institutional. Condom Cestino, Dr. Francisco, Havana, Cuba. Official. Contreras Duenas, Dr. Felix, Madrid, Spain. Institutional. Convit Garcia, Dr. Jacinto, Caracas, Venezuela. Official. de Cordova, Dr. Armando, Havana, Cuba. Institutional. Courbusier, Dr. Harold, U. S. A. Institutional. Costales Latatu, Dr. Guillermo, Havana, Cuba. Institutional. Creer, Mr. Ralph P., Chicago, Ill., U. S. A. Institutional. Curras Argiielles, Dr. Jesus, Marianao, Cuba. Institutional.

Dalgamouni, Dr. Mohamed, Cairo, Egypt. Official. Davey, Dr. T. F., UzuakoIi, Nigeria. Official. Davison, Dr. A. R., Pretoria, Union of South Africa. Official. Dharmendra, Dr., Calcutta, India. Official. Dteisbach, Dr. John A., St. Albans, W. Va., U. S. A. Private. Diaz Argiielles, Dr. Carlos, Havana, Cuba. Private. Diaz Jacomino, Dr. Evelio, Cienfuegos, Cuba. Private. Diniz, Dr. Orestes, Belo Horizonte, Brazil. Institutional. Dominguez Lopez, Dr. Francisco, Camaguey, Cuba. Institutional. Doull, Dr. James A., Washington, D. C., U. S. A. Institutional. Dubois, Dr. Albert, Antwerp, Belgium. Official. Duren, Dr. Albert N., Brussels, Belgium. Official. Duke, Mrs. Alice, Mexico, D. F., Mexico. Official.

Espinosa Valdes, Dr. Maximiliano, Havana, Cuba. Institutional. Estrada, Dra. Concepcion, Mexico. Official.

Farinas Guevara, Dr. Pastor, Havana, Cuba. Official. Feldman, Dr. William H., Rochester, Minn., U. S. A. Institutional. Fernandez, Dr. Jose M. M., Rosario, Argentina. Institutional. Ferrer Pulgaron, Dr. Ismael, Havana, Cuba. Official. Fester, Mrs. A., Antwerp, Belgium. Private. Figueras Ballester, Dr. Alfredo, Havana, Cuba. Institutional. Fiol, Dr. Hector, Buenos Aires, Argentina. Official. Fite, Dr. George L., Carville, La., U. S. A. Institutional. Floch, Dr. Herve, Cayenne, French Guiana. Official.

16,2 Leprosy News and Notes

Fonts Abreu, Dr. Ernesto, Havana, Cuba. Institutional. Forgan, Dr. Robert, London, England. Private. Fraser, Dr. N. D., Hong Kong, China. Institutional. Friberg, Dr. J. B., St. Paul, Minn., U. S. A. Institutional.

Galvez A., Dr. Ramiro, Guatemala. Official. Garcia Miranda, Dr. Adolfo, Havana, Cuba. Official. Garcia Ramos, Dr. Francisco, Tacubaya, Mexico. Institutional. Garzon, Dr. Rafael, Cordova, Argentina. Institutional. Garzon Camacho, Dr. Luis, Havana, Cuba. Institutional. Gass, Dr. Herbert H. Chandkuri, India. Institutional. Gay Prieto, Dr. Jose, Madrid, Spain. Official. Gomez Castellanjos, Dr. P., Havana, Cuba. Gomez Orbaneja, Dr. Jose, Madrid, Spain. Official. Gonzalez Peris, Dr. Guillermo, Havana, Cuba. Official. Gonzalez Prendes, Dr. Miguel A., Havana, Cuba. Official. Gougerot, Dr. Henri, Paris, France. Official. Grau Triana, Dr. Juan, Havana, Cuba. Institutional. Greiffenstein, Mr. Guillermo, Bogota, Colombia. Personal. Guillot, Dr. Carlos Federico, Buenos Aires, Argentina. Institutional.

Haedo Medina, Dr. Juan, Marianao, Cuba. Private. Herrera, Dr. Marcos A., Marianao, Cuba. Institutional. Herrera, Dr. Guillermo, Dominican Republic. Official. Hasselmann, Dr. C. M., Erlangen, Germany. Institutional. Hingson, Dr. Robert A., Memphis, Tenn., U. S. A. Private. Hoffmann, Dr. W. H., Havana, Cuba. Private. Horta, Dr. Antonio Carlos, Belo Horizonte, Brazil. Official. Hughlett, Dr. H. S., New Orleans, La., U. S. A. Private. Hurwitz, Dr. Ezra, Panama, Canal Zone, U. S. A. Private.

Ibarra Perez, Dr. Ramon, Havana, Cuba. Official. Isola, Dr. Renato, Brazil. Official.

Jacques Gentil, Mrs. Helena, Rio de Janeiro, Brazil. Official. ' Johansen, Dr. Frederick A., Carville, La., U. S. A. Official.

Kellersberger, Dr. Eugene R., New York, N. Y., U. S. A. Official. Karsner, Dr. Howard T., Cleveland, Ohio, U. S. A. Official. Kinnear, Sir Walter S., London, England. Institutional. Koppisch, Dr. Enrique, San Juan, Puerto Rico. Institutional.

Laosa, Dr. Ovidio, Havana, Cuba. Official. Lara, Dr. Casimiro B., Culion, Philippines. Official. Latapi, Dr. Fernando, Mexico, D. F., Mexico. Official. Lavernia, Dr. Frank, Havana, Cuba. Institutional. Lavin Dominguez, Dr. Francisco A., Havana, Cuba. Institutional. Laviron, Dr. P., Bamako, Fr. W. Africa. Official. Leon Blanco, Dr. Francisco, Havana, Cuba. Institutional. Leonard Capote, Dr. Rene A., Havana, Cuba. Institutional. Llano, Dr. Leonidas, Buenos Aires, Argentina. Official. Llano Ilarduya, Dr. Jorge, Marianao, Cuba. Official. Lomelli, Dr. Alirio I., Venezuela. Official.

Madeira, Dr. Jose Alcantara, Sao Paulo, S. P., Brazil. Official. Manalang, Dr. Cristobal, Manila, Philippines. Official.

193

194 International Journal of Leprosy

Martinez Dominguez, Dr. Victor, Madrid, Spain. Official. Marty, Dr. Ernesto, Havana, Cuba. Private. Maldonado Romero, Dr. Dario, Bogota, Colombia. Official. Mas, Dr. Miguel, Havana, Cuba. Institutional. Mauri, Dr. Antonio Carlos, Sao . Paulo, S. P., Brazil. Institutional. Mauze, Dr. Jean, Point-a-Pitre, Guadaloupe, F. W. 1. Official. Medina Alonzo, Dr. Edgardo, Yucatan, Mexico. Institutional. de Mello, Dr. Indalecio Froilano, Lisbon, Portugal. Official. Melsom, Dr. Reidar, Bergen, Norway. Official. Menchaca, Dr. Juan J., Guadalajara, Mexico. Institutional. Mendez, Dr. Jose Pessoa, Porto Alegre, Brazil. Official.

1948

Montestruc, Dr. Etienne, Fort de France, Martinique, F. W. 1. Official. de Mesquita, Dr. S. J. Bueno, Paramaribo, Surinam. Ins titutional. Mesa Ramos, Dr. Jose, Havana, Cuba. Official. Mestre, Dr. Juan Jose, Havana, Cuba. Official. de Mota, Dr. Joaquim Pereira, Rio de Janeiro, Brazil. Official. Muir, Dr. Ernest, London, England. Official. Muro Godinez, Dr. Nilo, Havana, Cuba. Institutional. Munoz Rivas, Dr. Guillermo, Bogota, Colombia. Official.

Nogueira, Dr. Pedro, Marianao, Cuba. Private. Noussitou, Dr. Fernando, Buenos Aires, Argentina. Official. Nudemberg, Dr. Albert, Rosario, Argentina. Institutional. Nunez Andrade, Dr. Roberto, Mexico, D. F., Mexico. Institutional.

Olmos Castro, Dr. N., Tucuman, Argentina. Institutional. Orsini de Castro, Dr. Olyntho, Belo Horizonte, Brazil. Institutional. Oteiza Setien, Dr. Alberto, Havana, Cuba. Institutional.

Palomo Pavon, Dra., Isabel, Mexico. Institutional. Pardo Castello, Dr. Vicente, Havana, Cuba. Official. Payne, Dr. Eugene H., Detroit, Mich., U. S. A. Institutional. Pedrera Rodriguez, Dr. Juan Jose, Havana, Cuba. Institutional. Pedroso Crucet, Dr. J., Guantanamo, Cuba. Institutional. Penalver Ballera, Dr. Rafael, Havana, Cuba. Institutional. Perches Franco, Dr. Jose, Mexico, D. F., Mexico. Official. Pereira, Dr. Jose Cerqueira Rodriquez, Belo Horizonte, Brazil. Institutional. Pesce, Dr. Hugo, Lima, Peru. Official. Peyri, Dr. Antonio, Monterrey, Mexico. Institutional. Peyri, Dr. Jaime, Barcelona, Spain. Institutional. Pie, Dr. Alfredo, Havana, Cuba. Private. Pina Martino, Dr. Jorge, Havana, Cuba. Official. Pineyro Rodriguez, Dr. Raul, Havana, Cuba. Institutional.

Quero Padilla, Dr. Roberto, Havana, Cuba. Institutional. Quiroga, Dr. Marcial I., Buenos Aires, Argentina. Official.

Rabello, Dr. Francisco E., Rio de Janeiro, Brazil. Official. Ramirez Sanchez, Dr. Alejandro, Gualalajara, Mexico. Institutional. Reaud, Dra. Bertha, Havana, Cuba. Institutional. Reenstierna, Dr. John, Stockholm, Sweden. Official. Rendon Guerra, Dr. Luis, Quito, Ecuador. Official. Riccardi, Sra. Amelia C., Argentina. Official. Richards, Dr. Oscar W., Buffalo, N. Y., U. S. A. Institutional. Rio Leon, Dr. Enrique, Santa Clara, Cuba. Institutional.


Risi, Dr. Joao Baptista, Rio de Janeiro, Brazil. Official. Risi, Dr. Vicente, Londrina, Parana, Brazil. Official. Rodrigues Plasencia, Dr. Luis, Havana, Cuba. Official. Rodrigues, Dr. Argimiro, Havana, Cuba. Private. Romero Jor dan, Dr. Oscar, Havana, Cuba. Institutional. Rosa, Dr. Cassio, Sorocola, S. P., Brazil. Institutional. Ross, Dr. J . Innes, Nairobi, East Africa. Official. Ross, Sr. Hilary, Carville, La., U. S. A. Institutional. Rotberg, Dr. Abrahao, Sao Paulo, S. P., Brazil. Official. Ryrie, Dr. Gordon A., London, England. Institutional.

Saenz Sotolongo, Dr. Arturo B., Havana, Cuba. Institutional. Saenz Ricardo, Dr. Braulio, Havana, Cuba. Official. Sagaro, Dr. Bartolome, Havana, Cuba. Institutional. Salazar Cruz, Dr. Severino, Santiago de Cuba, Cuba. Institutional. Sanchez, Dr. Aquilino, Madrid, Spain. Institutional. Salomao, Dr. Abrahao, Belo Horizonte, Brazil. Institutional. Sanchez Diaz, Dr. Jose L., Havana, Cuba. Institutional. Santos Silva, Dr. Manuel, Coimbra, Portugal. Official. Schujman, Dr. Salomon, Rosario, Argentine. Institutional. Serrano, Dr. Eugenio, Havana, Cuba. Institutional. Sigarreta, Dr. Angel, Santiago de Cuba, Cuba. Institutional. Silveira, Dr. Linneu Mattos, Sorocaba, S. P., Brazil. Official. Sloan, Dr. Norman A., Kalaupapa, T. H., U. S. A. Official. Slotkin, Dr. George E., Buffalo, N. Y., U. S. A. Private. Soule, Dr. Malcolm H., Ann Arbor, Mich., U. S. A. Official. de Souza Lima, Dr. Lauro, Gopouva, S. P., Brazil. Official. de Souza, Campos, Dr. Nelson, Sao Paulo, S. P., Brazil. Official. de Souza, Dr. Paulo Rath, Sao Paulo, Brazil. Official. Sowers Mendez, Dr. Guillermo, Havana, Cuba. Official. Stancioli, Dr. Jose, Belo Horizonte, Brazil. Institutional. Such Sanchez, Dr. Manuel, Spain. Official. Sullivan, Sr. Catherine, Normandy, Mo., U. S. A. Official.

Taboas Gonzalez, Dr. Manuel, Havana, Cuba. Institutional. Thompson, Mr. W. E., London, England. Private. Tiant, Dr. Francisco R., Havana, Cuba. Official. Trespalacios, Dr. Fernando, Havana, Cuba. Official.

Urzua, Dr. Juon Jose, Guadelajaro, Mexico.

Valdes Alvarino, Dr. Andres, Havana, Cuba. Institutional. Valdes Dapena, Dr. Antonio, Havana, Cuba. Official. Valhuerdi, Dr. Conrado, Cristo, Or., Cuba. Official. Van Studdiford, Dr. M., New Orleans, La., U. S. A. Official. Vargas, Dr. Oscar, Washington, D. C., U. S. A. Institutional. Vegas Sanchez, Dr. Martin, Caracas, Venezuela. Private. Vega Hernandez, Dr. Sabas, Havana, Cuba. Institutional. Vilanova Montiu, Dr. Xavier, Barcelona, Spain. Institutional.

Wade, Dr. H. W., Culion, Philippines. Institutional. Weaver, Mrs. Eunice, Rio de Janeiro, Brazil. Institutional. Wharton, Dr. L. H., Mahaica"British Guiana. Institutional. Wilkinson, Dr. Henry, Bermuda. Official. Wilson, Dr. R. M., Richmond, Va., U. S. A. Private.

195


Yew, Dr. Chia Chun, Tsinan, China. Official.

COUNTRIES AND TERRITORIES REPRESENTED

The following tabulation of the countries and significant political sub-divisions or territories represented by the members, also includes data on the membership of the International Leprosy Association who attended-a total of 142, of whom 52 joined during the Congress week. It has not been possible to attempt, as was done in the report of the Cairo Congress, to indicate which entities were represented officially.

Country or Territory

Argentina ............................... . Belgium (and Belgian Congo) .............. . Bermuda ........... .. ................... . Brazil ................... .... ........ . . . . . British East Africa ........................ . British Guiana, B. W. I. ................... . China .......... . ................... . .... . Columbia .............. . ................. . Cuba ................. . ................. . Dominican Republic ....................... . Ecuador ...................... . .......... . Egypt .............. .. ................ . .. . England ................................. . Fiji ..................................... . France ....... . ............. . ............ . French Guiana ... .. .. ... .................. . French West Africa ..... . . . .............. . Germany .................. . ............. . Guadeloupe, F. W. I. . .. ................... . Guatemala ........ . ................... . . . India ... ... ...... . .... . .................. . Martinique, F. W. I. . .... . ................ . Mexico .............. .... ................ . Nigeria .......... ... ................. . .. . Norway .... . ..... ... . . .................. . Peru ... . ................................ . ·Philippines .............................•. Portugal ....... . ......................... . Spain ................................... . Spanish Guinea ........ ... ............ . ... . Surinam ................................. . Sweden ........ . ........................ . Trinidad ........ .. ...................... . Union of South Africa .. .. .. .. ............ . . United States, Continental ................. . United States, Hawaii ... . ................. . United States, Canal Zone .............. .. . .

Congress Members

15 3 1

28 1 1 2 3

76 1 1 1 6 1 2 1 1 1 1 1 3 1

16 1 1 1 3 3

10 1 1 1 1 1

28 2 1

Association Members 8 (3 new) 3 o

22 (8 new) 1 1 1 2

49 (19 new) 1 (new) e o 4 o 1 1 1 (new) 1 (new) 1 (new) o 3 1 (new) 6 (5 new) o 1 1 2 (1 new) 1 (new) 6 (all new) 1 1 1 o 1

15 (3 new) 2 1


Country or Territory

United States, Puerto Rico ................ . Venezuela ..........•.....................

TOTALS ... .' .................. .

Members Congress

1 3

226 Congress Members: Cuban 76, foreign 150, total. . . . 226 Countries and territories represented . . '.' . . . . . . . . . . 40

197

Members Association o 2 (1 new)

142 (52 new)

Comparative statistics of the Cairo Congress.-It has been deemed of interest to compare the membership and representation of the Cairo and Havana Congresses, which in certain respects-but naturally-differed widely.

Members of the Cairo Congress: Egyptian 60, foreign 107, total 167. Countries and territories represented by members, 48. Countries and territories represented at Havana, not at Cairo: 18.

These entities contributed 44 members, as follows: Bermuda (1), Dominican Republic (1), Ecuador (1), French Guiana (1), French West Africa (1), Guadeloupe, F. W. 1. (1), Guatemala (I), Mexico (16), Martinique, F. W. 1. (1), Peru (1), Portugal (3), Spain (10), Spanish Guinea (1), Surinam (I), South Africa (1); United States territories: Hawaii (2), Canal Zone (I), Puerto Rico (1).

Countries and territories represented at Cairo, not at Havana: 27. These entities contributed 35 members, as follows: Basutoland (1), Bulgaria (I), Camerouns (1), Ceylon (I), Cyprus (1), Czechoslavakia (I), Denmark (1), Estonia (2), Formosa (1), Hungary (1), Indo-China (1), Iran (2), Iraq (1), Italy (3), Japan (I), Jugoslavia (I), Korea (I), Malaya (2), Malta (1), Netherlands India (3), Palestine (1), Paraguay (1), Poland (2), Rhodesia (1), Syria (I), Tunis (1), Uruguay (1).

The broad regional distribution of the membership of the two Congresses is shown in the following tabulation,

Havana Cairo Territories Members Territories Members

1. Western Hemisphere (Counting extra-Continental

U. S. A. territories sepa-rately) ... : .......... ..

2. Europe (Incl. Mediterranean islands; . and Belgium and Belgian

Congo as two units) .... . 3. Africa

(Entire; all territories except Belgian Congo sepa-rate) ............... . . .

4. Near and Far East (Inc!. Fiji) .......... .... .

TOTAL .......... .

21

9

6

4

40

*Including 80 of the host country. tIncluding 60 of the host country.

184* 10 27

27 16 34

6 8 70.t

9 15 36

226 49 167


MINUTES OF THE OPENING PLENARY SESSION

The first assembly of the Congress was held with Dr. Otezia, head of the Congress Council as organized (see elsewhere), in the chair, Dr. Ferrer serving as Secretary.

The action of the organizing group in setting up a temporary Congress Council was ratified.

The action of the temporary Congress Council in establishing an Executive Committee was ratified, with the addition of three other members nominated from the floor.

Officers of the Congress, as proposed by the Council, were elected, as follows:

Dr. A. Oteiza, President Dr. H. W. Wade, Associate President Dr. 1. Ferrer, General Secretary Dr. E. Muir, Program Secretary

It was proposed that six committees be created to prepare and present to the final plenary session, specific reports and proposals, as follows: (1) Therapy, (2) Classification and Nomenclature, (3) Epidemiology and Control, (4) Social Welfare, (5) Use of the Words "Leper " and "Leprosy," and (6) Editorial; and tentative lists of members of those committees were offered. The proposal was approved, with some changes as regards personnel of the committees and with the proviso that the committees might add to their own numbers with the approval of the Executive Committee. (The committees as finally established are enumerated in connection with the technical resotions, elsewhere.)

The session adjourned, to resume as the first scientific session.

MINUTES OF THE CLOSING PLENARY SESSION

The final session of the Congress convened on Sunday, April 11, 1948, at 9 a. m., with Dr. Alberto Oteiza, President of the Congress, in the chair. Also participating were Vice-President Dr. H. W. Wade, Secretary Dr. Ismael Ferrer, and Vice-Secretary Dr. E. Muir.

1. The reports of the committees, which as passed by the Editorial Committee had been mimeographed and distributedtogether with Spanish translations in four instances-were read, discussed and acted upon. (Such changes as were made are incorporated in the technical reports as published.)

(a) Committee on Therapy.-The report of this committee

16,2 Leprosy News and Notes 199

was approved with a few small changes and certain additions of slight importance.

(b) Committee on Classification and N omenclature.-After a lengthy discussion the first part of the report was adopted without change. The second part, concerning which there was much diversity of opinion with respect to particular features, was rejected in toto.

(c) Committee on Epidemiology and Control.-This report was the subject of considerable discussion, and several changes were proposed. When, however, the question was put whether or not the proposed amendments should be considered in detail .01' report be adopted as originally presented, the latter alternative was approved by a large majority.

(d) Committee on Social Assistance.-There being nothing controversial in this report it was approved as presented. A proposal that a Cartilla of information on the epidemiology, control and prophylaxis of leprosy, prepared by Prof. Baliiia for popular instruction, be published or approved by the Congress was approved.

(e) Committee on the Words "Leper" and "Leprosy".Accepted without change.

(I) Editorial Committee.-This committee,* created primarily to edit the reports of the technical committees, had no special r eport to present. Its work obviously could not be finished until the different technical reports were finally acted upon by the Congress.

2. Mr. Per ry Burgess, invited by the Council to represent the Congress as a whole, eloquently moved for an expression of its deep gratitude to the Government of the Republic of Cuba for its generous hospitality, and of its respect to the Honorable President of the Republic, Dr. Ramon Grau San Martin. Appreciation was extended to all those concerned with the organization of the Congress and the carrying out of the scientific and social programs.

To the Minister of State, for the invitation sent to the respective Governments and for the banquet which terminated the program of the Congress.

To the Minister of Health and Social Assistance, for his

*The Editorial Committee was composed as follows: Dr. H. W. Wade (Chai rman), Dr. M. H. Soul~ (Secretary), and Drs. R. Chaussinand, C. F. Guillot, J. J. Mestre, E. Muir, G. A. Ryrie, Braulio Saenz and L. Souza Lima.


invaluable cooperation and for the reception offered to the delegates and thei:r friends.

To the National Organizing Committee, specifically to its President Dr. Alberto Oteiza and Secretary Dr. Ismael Ferrer, and generally to the other members.

To the general officers of The International Leprosy Association, Drs. H. W. Wade and E. Muir, and its council members who participated on the Congress Council.

To the Minister of Communications, for the issuance of a special postage stamp in commemoration of this Congress.

To the Mayor of Havana, for having permitted the use of the Escuela Municipal Valdes Rodriguez and for the tea offered at the Municipal Palace.

To the Governor and Council of Mayors of the Province of Havana, for a picnic luncheon.

To the President of the Sociedad Cuban a de Dermatologia, for a reception offered by the Society at the Club de Profesionales.

To the Colegio Medico N acional, for the cocktail party at the headquarters of that organization.

~o the Ladies Committee, for the kindness shown to the lady members of the delegations and the wives of foreign delegates, and for the luncheon party held for them.

To the Press, for the active dissemination of the news emanating from the Congress through the Cuban and foreign newspapers.

To the interpreters, for their efficient work which made possible the completion of the program within the allotted- time.

And finally to all others whose work contributed to the success of the meeting.

This expression of gratitude and appreciation was approved, with applause.

3. Dr. J. M. M. Fernandez, of Argentina, moved that the members stand in memoriam of the many masters of leprology who had died since the Cairo Congress, among them Drs. Rabello, Fidanza, Lie, Puente, Rose, McKinley, Hopkins and Faget. It was so done.

4. There then arose the matter of the place of the next Congress, not on the agenda. The Government of India, by means of a cablegram to its official representative, Dr. Dharmendra, had extended to the International Leprosy Association an invitation to hold the next congress in Calcutta in 1953. This matter was to be considered at the meeting of the Asso-


ciation, immediately after the final plenary session. The Spanish delegation, however, had given verbal information of an invitation from the Government of Spain, and there was presented a petition bearing the signatures of 51 members from 15 countries, proposing that the Congress itself should decide the matter and that the next such meeting should be held in Madrid. Dr. Pardo Castello moved that both invitations be accepted "in principle" and that the matter be referred to the International Leprosy Association, its executive body to make the final decision as to the place two years before the Congress date by means of a referendum. This proposal was rejected by a majority, and it was finally voted that the next Congress take place in Madrid, Spain, in 1953.

There being no further business, the session adjourned for a group photograph, after which a meeting of the International Leprosy Association would be held.

TECHNICAL RESOLUTIONS OF THE CONGRESS

Here are presented, in both English and Spanish, the resolutions on technical and related matters adopted by the Congress in the final plenary session. They constitute the reports of the corresponding committees with certain modifications made by majority vote; but since upon modification and adoption they constituted acts of the Congress itself, the Editorial Committee has changed the phraseology where they appeared as recommendations to the Congress by the Committees concerned. Each resolution is followed by the discussion · from the floor, insofar as that is represented by notes submitted by the speakers.

f CLASSIFICATION AND NOMENCLATURE* INTRODUCTION

The great diversity in the forms of leprosy has led to many attempts to establish systems of classification. Hansen and Looft (1894) put forward a well founded division into two types. Several workers in the period of the Berlin Conference (1897) attempted to distinguish certain varieties within these

*The Committee on Classification and Nomenclature was composed as follows: Dr. V. Pardo Castello (Chairman), Drs. J. M. M. Fernandez and H. L. Arnold (Secretaries), and Drs. C. J. Austin, G. Basombrio, R. ChauBsinand, Dharrnendra, A. Dupois, J. Gay Prieto, H. T. Karsner, F. Latapi, H. Pesce, J. Aguiar Pupo, F. E. Rabello, G. A. Ryrie, N. Sousa Campos, F. R. Tiant, M. Vegas and H. W. Wade.


two forms. The first attempt to establish an internationally acceptable formula of classification was made by the Leonard Wood Memorial Conference, held in Manila in 1931. The classification then put forward-which was primarily clinico-anatomical, including the bacteriological factor and to a certain extent the histopathology-was amplified and extended by the International Congress held in Cairo in 1938; and that system still prevails in many parts of the world.

Previous to that time attempts had been made, by a group which constituted a minority at the Cairo Congress, to expand the basis of classification. More emphasis than previously was laid upon the histopathological characteristics, and the immunological factor as represented by the lepromin reaction was introduced. It had long been felt that any satisfactory classification must be a natural one taking into account the greatest possible number of facts and establishing the most homogeneous categories possible; and that these categories must be based on essential and constant characteristics. The efforts of this group led to the development of the South American Classification, which was designated the Pan-American Classification at a conference held in Rio de Janeiro in 1946.

The Classification Committee of this Congress, in a serious attempt to reconcile and unify these apparently discordant systems, arrived at a formula which is believed to be based on a biologic interpretation of the clinical facts. The criteria, on the basis of which the three classes herein defined are established, are in diminishing order of availability: (1) clincal, (2) bacteriological, (3) immunological, and (4) histopathological.

It is proposed that the classification division of leprosy into two types "polar" (Rabello, 1938) in their essential characteristics and relatively stable in their evolution, be recognized and maintained, and that they be designated:

Lepromatous (malignant, or gravis) : symbol, L. Tuberculoid (benign, or mitis) : symbol, T. It is also proposed that, in addition, recognition be given a

group of cases of less distinctive or positive characteristics, less stable and less certain with respect to evolution, and that it be designated:

Indeterminate (undifferentiated): symbol, 1.

I')

I 1 Jl


DEFINITIONS

The characteristics of these three classes of leprosy are as follows:

Lepromatous type.-Minimal resistance to the existence, multiplication, and dissemination of the bacilli; constant presence of large numbers of bacilli in the lesions, with a distinctive tendency to form globi; characteristic clinical manifestations in the skin, mucous membranes (especially those of the upper respiratory tract and eye), and/ or the peripheral nerves, together with involvement of other organs; regular failure to react to lepromin; pathognomic granulomatous structure of the lesions; marked stability of type and a tendency to progression. These cases are "infectious" or "open."

Tuberculoid type.-High resistance to the existence, multiplication, and dissemination of the bacilli; bacteriologically negative as a rule or, if positive, with few bacilli except in reactional states; characteristic clinical manifestations, mainly in the skin and nerves, tending to be limited in extent and varying in degree with the reactivity of the tissue; reactivity to lepromin in a very high percentage of cases; nearly always a tuberculoid granulomatous structure in active lesions; marked stability, and a strong tendency to spontaneous regression in the absence of repeated reactions. These cases are usually "noninfectious" or "closed."

Indeterminate group.-Variable with respect to resistance; clinical manifestations chiefly in the skin and nerves; the skin lesions usually flat macules, either hypochromic, erythematohypochromic or erythematous; bacteriologically negative as a rule or, if positive, with few bacilli; lepromin reaction usually negative or moderately positive; the lesions histologically of simple inflammatory nature; stability much less than in either of the (polar) types; and a variable tendency with regard to persistence, progression, or regression, or transformation into one of the polar types. These cases are usually "noninfectious."

CLINICAL SUBDIVISION OF CASES

The fundamental aim of any classification of a leprosy case being the determination of the type or group to which it belongs, in accordance with the foregoing definitions, certain members of the Classification Committee held that the "subtypes" of other systems merely correspond to clinical aspects of variable importance. These aspects can be considered from different points of view, namely:

204 International Jourrw,l of Leprosy 1948

Degree of severity (as, for example, the Ll1 L2 , La' of the Memorial Conference classification) ;

Manner of evolution (slow or rapid, stationary or progressive, reactional states, etc.) ;

Localization (skin, nerve, eye, systemic, etc.) ; Morphology (macules, nodules, "plaques," diffuse infiltra

tions, etc.) ; Clinical form (classical nodular lepromatosis, diffuse lepro

matosis of Lucio, etc.). [The remainder of the report of the Classification Com

mittee, adopted by it with minority disagreement, comprised a suggested scheme of subtyping cases, with names and definitions, and a section of reactional conditions. That part of the report was rejected by the Congress. A proposed appendix setting forth details of investigative procedures was not considered at all.]

( CLASIFICACION Y NOMENCLATURA*

INTRODUCCION

La gran diversidad en la formas de lepra ha suscitado muchas tentativas para establecer sistemas de clasificacion. Hansen y Looft habian sefialado una bien fundada division de la enfermedad en dos tipos. Vaiios auto res en el periodo de la Conferencia de Berlin intentaron distinguir ciertas variedades dentro de esas dos formas. EI primer intento para formular una clasificacion internacionalmente aceptable fue realizado por la Conferencia de la Leonard Wood Memorial reunida en Manila, en 1931. La clasificacion establecida entonces, la cmU era primitivamente clinico-anat6mica, incluyendo el factor bacteriol6gico y hasta cierto punto la histopatologia, fue modificada y extendida por el Congreso Internacional reunido en el Cairo en Marzo de 1938, y esta clasificaci6n todavia perdura en diversas partes del mundo.

Ya con anterioridad un grupo, que constituy6 la minoria en el Congreso del Cairo, habia realizado tentativas para amp liar las bases de la clasificaci6n. Concedia mayor importancia a la histopatologia e introducia el factor inmunologico representado por la reactividad a la lepromina. Desde hace mucho tiempo se ha pensado que cualquier clasificaci6n para ser satisfactoria

*The Spanish version of the Committee's report was prepared by a group of its members, and corrected from the final English version by Dr. F. R. Tiant.


debe tener bases naturales, y por consiguiente tener en cuenta el mayor numero de hechos y agruparlos en categorias cada una 10 mas homogenea posible, fundadas en caracteres esenciales y constantes. Los esfuerzos de ese grupo condujeron al desarrollo de la llamada Clasificacion Sudamericana, luego designada como Pan americana en una Conferencia reunida en Rio de Janeiro en Octubre de 1946.

EI Comite de Clasificacion de este Congreso en un esfuerzo serio para conciliar y unificar estos dos sistemas de clasificacion aparentemente discordantes, ha llegado a una formula que se considera basada en la interpretacion biologica de los hechos clincos. , Los criterios sobre los cuales se basa el establecimiento de las tres clases aqui definidas son, por orden decreciente de accesibilidad : 1) clinico, 2) bacteriologico, 3) inmunologico, y 4) histopatologico.

Se propone que se reconozca y se mantenga la division cIasica de la lepra en dos tipos fundamentales-"polares" (Rabello 1938) -en sus caracteristicas esenciales, y relativamente estables es su evolucion y que se designen:

L epromatoso (maligno 0 gravis) : simbolo L. Tub erculoide (benigno 0 mitis) : simbolo T. Se propone ademas que en adicion se reconozca un grupo de

casos con caracteres menos distintivos, menos estables e inciertos con respecto a su evolucion y que se designe:

Indeterminado (indiferenciado): simbolo I.

DEFINICIONES

Las caracteristicas de estas tres clases de lepra son las siguientes:

Tipo lepromatoso.-Resistencia minima a la presencia, multiplicacion y disemillaci6n de los bacilos; presencia con stante de un gran numero de bacilos en las lesiones con tendencia marcada a formar globi; manifestaciones clinicas peculiares en piel y mucosas (especialmente elIas de vias respiratorias superiores), oj os, nervios perifericos y otros organos; negatividad habitual de la leprominoreaccion; estructura granulomatosa patognomonica. Con respecto a la evolucion: marcada estabilidad de tipo, y tendencia al empeoramiento progresivo. Estos son los casos "infectantes" 0 "abiertos".

Tipo tuberculoide.-Alto grado de resistencia a la presencia, multiplication y diseminacion de los bacilos; baciloscopia generalmente negativa 0 presencia de escasos bacilos, E'xcepto en los estados reaccionales en donde pueden ser abundantes; manifesta-

206 International Journal oj Leprosy 1948

ciones clinicas peculiares predominantes en piel y nervios perifericos, con tendencia a la limitaci6n en la extension y de grado variable segun la reactividad tisular; positividad de la leprominoreaccion en alto porcentaje de casos; estructura granulomatosa tuberculoide practicamente con stante en lesiones activas; marcada estabilidad de tipo y fuerte tendencia a la regresion expontanea en ausencia de reacciones repetidas. Estos casos son habitualmente "no infectantes" 0 "cerrados".

Grupo indeterminado.-Resistencia variable, manifestaciones clinicas predominantes en piel (manchas lisas hipocr6micas, eritemato-hipocromicas 0 eritematosas) yen nervios perifericos; baciloscopia en general negativa 0 con escasos bacilos; leprominoreaccion negativa 0 debilmente posit iva ; histol6gicamente las lesiones tienen estructura inflamatoria simple; estabilidad de caracteres mucho menor que ]a de cualquiera de los tipos (polares) ; y tendencia variable respecto a persistencia, progresion regresion 0 transformacion en alguno de los tipos polares. Estos cas os son habitualmente "no infectantes."

SUBDIVISIONES CLINICAS DE LOS CASOS

Siendo 10 fundamental en la clasificaci6n de los casos de lepra la determinacion del tipo 0 grupo al que pertenezcan, de acuerdo con las definiciones antes expresadas, cierlos miembros del Comite de Clasificacion sostuvieron que los "sub-tipos" de otros sistemas, simplemente correspond en a aspectos clinicos de importancia variable que pueden ser estudiados desde diversos puntos de vista:

Grado de avance (como, por ejemplo, los LlI L2 , L3 , de la clasificacion de Manila) ;

Modo de evoluci6n (lento 0 rapido, estacionario 0 progresivo, estados reaccionales, etc.) ;

Localizaci6n (cutanea, nerviosa, ocular, sistemica, etc.) ; M orjologia (maculas, nodulos, "placas," infiltracion difusa,

etc.) ; Individualidad clinica (lepromatosis nodular clasica, lepro

matosis difusa de' Lucio, etc.). [EI resto de la ponencia del Comite de Clasificacion aprobado

por el voto de la mayo ria de este, contenia un propuesto esquema para dividir en sub-tipos los casos, con nombres y definiciones y una seccion con referencia a los estados reaccionales. Esta parle de la ponencia fue rechazada por el Congreso. Un apendice exponiendo los detalles de los procedimientos de investigacion no fue considerado.]


DISCUSSION

Dr. Joaquin Motta (Brazil): Propongo dividir el reporte en dos partes: la primera [after p. 3 of the mimeographed copy under consideration] y la segunda desde ahi en adelante. Hago constar mi voto a favor de la primera y en contra de la segunda. La primera parte representa un gran progreso sobre las clasificaciones anteriores; Ie segunda usa una terminologia que no corresponde dentro de la semiologia general de la piel. No se puede admitir que se use para la lepra una terminologia diferente de aquella adoptada para las demas enfermedades con manifestaciones cutaneas.

Dr. Jose M. M. Fernandez (Argentina): El Comite de Clasificacion acepta todas las sugestiones tendientes a perfeccionar el esquema propuesto. Cabe sefialar, como ya la expresa el preambulo, que la preocupacion fundamental de este Comite ha sido la de definir los grupos principales considerando en cambio que la clasificacion de las variedades tienen menD importancia. En este senti do el Comite considera que se debe dejar amplia libertad para establecer otros sub-tipos 0 variedades, ya sea de acuerdo a la evolucion, morfologia, grado de avance, etc.

Dr. Fernando Latapi (Mexico): La clasificacion propuesta refleja el acuerdo actual de las grandes escuelas leprologicas sobre 10 fundamental en este tema. Lo referente a aspectos clinicos es amplio, variado y sujeto a multiples opiniones y subdivisiones, pero es secundario, y entra mas bien en el capitulo de una descripcion cuidadosa de la enfermedad.

Dr. Dharmendra (India): (1) As a member of the Committee I am surprised that the report includes no indication of the fact that it was not unanimously adopted by the Committee. A number of members, representing some of the most highly endemic areas and dealing with large numbers of cases of leprosy, declared themselves against the report in no uncertain terms. (2) Some of the objections against the proposed classification are: (a) The term "tuberculoid macule" is proposed to indicate the well-known clinical entity represented by the maculo-anesthetic type of leSions, i. e., the flat hypopigmentated anesthetic patches. In justification of the use of this term it is stated that the lesions are almost always invariably tuberculoid to some degree, and that the patients are almost always lepromin-positive. But this is not borne out by actual studies in India, since these criteria are fulfilled only in about 50 per cent of the cases. (b) The terms " tuberculoid," "lepromatous" and "indeterminate" polyneuritis are redundant and confusing. Signs of nerve involvement in the cases with skin lesions of any type should not need the creation of any special varieties or subtypes, any more than some other symptoms, e.g., alopecia or iritis. The cases with only nerve involvement, without any skin lesions, are not common and their classification into tuberculoid, lepromatous and indeterminate is neither practicable nor necessary. (Argument incomplete.)

Dr. T. F. Davey (Nigeria): The first part of the report represents a real advance. The second part is open to criticism: (a) The proposed subdivisions are confusing to field workers, especially where flat macules are concerned. (b) In Nigeria the indeterminate group is not merely a group but covers a considerable, proportion of all cases, and embraces types not described in the proposals. I propose deletion of the sentence: "Indeterminate cases are usually non-infectious" [po 3 of the original].


Dr. Carlos Federico Guillot (Argentina): Dada la importancia practica y especulativa de la sugestion del Profesor Mota, no creo redundamente la reiteracion de nuestro apoyo hacia ella; es decir, que se apruebe la primera parte del informe, y sea objetada la segunda. En nuestro caso particular de medicos encargados de la compana antileprosa, con el deber de formar personal medico y tecnico, encontramos que la subdivisiones clinicas carecen de exactitud y son excesivamente frondosa. Nada men os que once sub-divisiones, sobre las cuales hay que injertar un sistema numerico que creiamos ya superado. Creo que Ilu aprendisaje no es compensado por su utilidad.

Dr. Hector Fiol (Agrentina): Apoyamos la mocion del Prof. Mota sobre la necesidad de discutir el informe de la clasificacion a dos partes. Estamos de acuerdo con la primera parte. En 10 que respecta a la segunda parte no comparto 10 propuesto porIa comision, incluyeno la variedad maculo-anestesico en el tipo tuberculoide, ya que dicha variedad es mas comun observarla en el grupo indeterminado. Su inclusion en el tipo tuberculoide crearia un gran confusionismo en el estudio clinico de los enfermos y clasificacion en las distintas partes del mundo, especialmente en aquellas don de no han aplicado hasta ahora esta clasificacion. Propongo la modificacion siguiente en las variedades del tipo tuberculoide: (a) macular simple; (b) macular figurada 0 elevada; (c) polineuritica; (d) maculo-neural.

Dr. Hugo Pesce (Peru): Pi do se aclare que la proposicion de la segunda parte porIa Comision de Clasificacion es facultativa y como tal debe aprobarse.

Dr. L eonidas Lleras (Argentina): Que sea la misma .comision de Clasificacion la encargada de buscar los terminos equivalentes dermatologicos que se necesitan para aclarar los sub-tip os.

Dr. F ernando Noussitou (Argentina): La descripcion dermatologica es difusa, imprecisa, inconexa, no siendo posible formarse una idea clara del aspecto clinico de las sub-formas. La palabra alergia 0 hiperergia de utiIidad para la comprension de la forma tubereuloide ha sido omitida en el informe.

Dr. Guillermo Basombrio (Argentina): A mi juicio, en el ultimo parrafo se ha deslizado un error. Creo deber ser redactado asi: "Existe tambien la posibilidad de que un caso lepromatoso bajo ciertas circunstancias se transforma en tuberculoide como ha sido senalado por algunos autores" (Souza Lima).

Dr. Eduardo Borrell Navarro (Cuba): Declarar que es posible, salvo des de luego casos excepcionales, la transformacion de un caso tuberculoide en lepromatoso como ha sido ya sefialado pOl' algunos autores.

Dr. Harry J. Arnold (Hawaii): It is proposed to insert in the first paragraph of the introduction immediately following the first sentence, the following: "Hansen and Looft (1894) were the first to recognize two mutually incompatible forms of leprosy. Several workers in the period of the Berlin Conference (1897) attempted to distinguish certain varieties within these two forms." The word "inclusion" [po 4, line 25 of the mimeographed original] does not make sense; "diagnosis" was the word originally used and should be restored. [The first proposal refers to an insertion agreed upon in the Classification Committee but inadvertently left out of the final draft. The second proposal refers to a change made by the Editorial Committee; the original word was restored later. EDITOR.]


f THERAPY*

INTRODUCTION

209

From opmlOns expressed at the Rio de Janeiro Conference in 1946, and at this present International Congress, it is evident that much progress has been made in the treatment of leprosy since the Congress held in Cairo in 1938. Advances have been seen in respect to both the introduction of the sui phone group of drugs and the employment of hydnocarpus (chaulmoogra) oil in increasing dosages.

While the therapeutic activity of those drugs is evident, their action on the casual organism appears to be slow. It is therefore urged that further investigations be encouraged, for the purpose of increasing the effectiveness of these remedies.

It is considered advisable to lay down general directions with regard to the administration of remedies in accepted use in the therapy of leprosy.

DERIVATIVES OF DIAMINO-DIPHENYL SULPHONE

It is affirmed that the drugs of the sulphone group satisfy the conditions enumerated under the heading "Minimal Therapeutic Requirements" (see Research).

Existing evidence shows that these drugs are of great value in lepromatous leprosy, and many workers are of the opinion that they offer the best available therapy in this condition. Their use in cases of that type is therefore recommended. These drugs are particularly effective in moderately advanced and advanced cases; and they are of great value with respect to lesions of the nose and throat. Eye lesions frequently improve. Clinical improvement is noted first; bacteriologic improvement is much slower. Changes in the morphology of M. leprae accompany the clinical improvement.

It is the opinion of this Congress that the sulphones are the present drugs of · election for the treatment of leprosy.

SULPHONE DRUGS IN USE

The drugs used are, in chronologic order, promin (promanide), diasone (diamidine) and sulphetrone. The intrinsic bacteriostatic efficacy of these drugs may be regarded as iden-

*The Committee on Therapy was composed as follows: Dr. L. Souza Lima (Chairman), Dr. R. G. Cochrane (Secretary), and Drs. J. Barba Rubio, G. Brownlee, J. Convit,. T. F. Davey, Orestes Diniz, W. H. Feldman, H. Fiol, H. Floch, F. A. Johansen, C. B. Lara, J. G. Orbeneja, S. Schujman, F. Trespalacios, H. Vega and L. H. Wharton.


tical, so that similar effects may be expected from equivalent tissue concentrations. Systematic study has not yet been sufficient to permit dogmatic statements regarding dosage. The

. dosage schedules used in tuberculosis have in general been recommended, and the following are suggested as suitable.

Promin (diamino-diphenyl sulphone dextrose sodium sulphonate) .-In adult patients in good general condition and with a normal blood picture, an initial dose of 2 gm. in 5 cc. of solution is given intravenously daily. This dose should be increased after one to two weeks by 1 cc. daily until a dose of 12.5 cc. is reached. The dosage for children depends on age, weight, general physique, and individual tolerance. The drug should be administered daily for from one to three months, followed by a rest period of from one to two weeks, after which treatment is resumed. The dosage and the length of the rest periods may be modified in accordance with the requirements of the individual patients.

Diasone (disodi urn formaldehyde sulphoxylate of diamino-diphenyl sulphone) .-The following dosage is suggested: .

1st week: 0.3 gm. (1 tablet ) daily for 6 days, Qne day of rest, 2nd week: 0.6 gm. (2 tablets) daily for 6 days, one day of rest, 3rd week: 0.9 gm. (3 tablets) daily for 6 days, one day of rest.

In the fourth week and thereafter the dosage may be increased up to a maximum of six tablets (1.8 gm.) a day if tolerated; the dosage should be modified according to the tolerance of the individual. A rest period of one to two weeks should be allowed after every two months of treatment.

Sulphetrone (tetrasodium 4 :4'-bis y- phenylpropylaminodiphenyl-sulphone- d:y :d' :y' :-tetrasulphonate) .-This drug is freely soluble and available for parenteral or oral use. A concentration of 5 mgm. per 100 cc. of blood in ambulatory patients is recommended. This concentration is usually obtained in adults by daily total doses of 3 to 6 gm. given orally. A suitable initial dose is 0.5 gm. three times daily with, at intervals, 0.5 gm. increments of the total daily dose until the required amount is reached. Suitable doses for children appear to be 1.5 to 3 gm. daily. The drug should be given continuously for six months when a rest period may be allowed, depending on the tolerance of the patient.

TOXICITY OF THE SULPHONE DRUGS

All sulphone drugs are potentially haemotoxic. Anaemia is produced, which may appear soon after the first administration.


This condition varies in degree in different individuals, and may necessitate the interruption of treatment. In most cases however some degree of tolerance develops and the blood tends to return to normal. Sulphone medication should be accompanied by continuous adminIstration of iron and vitamin B complex; liver extract and thiamine chloride should also be used.

Certain phenomena in leprosy appear or are exacerbated at some stage of sulphone therapy. These may be characterised by acute skin reactions, sometimes called erythema nodosum leprosum, and also by iritis. These phenomena may indicate an increase or decrease of dosage, or a temporary suspension of the treatment.

Drug sensitivity occurs, though infrequently. Its incidence appears to be less where adjuvant vitamin B therapy is given. Should sensitivity occur, the drug should be discontinued at once.

LABORATORY CONTROL

In view of the haemotoxic action of the sulphones it is desirable that their use should be subject to adequate laboratory control. It is appreciated that absorption and excretion vary considerably.

Patients in whom inadequate renal function is suspected should from time to time be subjected to routine urine tests, and occasional blood-urea estimations.

DERIVATIVES OF HYDNOCARPUS (CHAULMOOGRA) OIL

It is the opinion of many workers that hydnocarpus (chaulmoogra) oil and its derivatives are effective in lepromatous leprosy, and that the maximum benefit is seen when these remedies are used in adequate and regular doses. Failure of these drugs is most often due to inadequate dosage and irregular administration. The preparations in general use are (a) the pure oil with 0.5 % to 4 % creosote, and (b) the ethyl esters, with 0.5 % to 4% creosote or 0.5 % iodine.

It is increasingly evident that the greatest benefit results from high dosage (15 to 25 cc. weekly), given regularly and divided between the subcutaneous, intramuscular, and intradermal routes. The maximum dose ultimately to be used depends on individual tolerance. Some patients are able to begin with relatively large doses and to continue even up to 40 to 50 cc. per week. Others cannot tolerate more than 10 cc., while in some the maximum dose must be still lower. The patient's


tolerance can frequently be increased by careful regulation of dosage. In this connection the quality of the oil or esters is of great importance.

It is recommended that the maximal dosage of 15 to 25 cc., or more if considered advisable, be reached as quickly as possible.

While some authorities consider that large doses can be given despite reactions, it is usually recommended that when that condition appears the amount given should be reduced or the treatment suspended, depending upon the severity of the reaction. Similar reduction or cessation of treatment may be necessary if there is local reaction or increase in the activity of eye lesions. Rest periods of fifteen days may be advised after every three and a half months treatment.

SUPPLEMENTARY MEASURES

While it is advisable to use hydnocarpus (chaulmoogra) or suI phone therapy in leprosy, it would be unfortunate if the generally accepted treatment were confined to those drugs, without due attention to other remedial measures. The following are therefore particularly emphasised:

Alleviation of disabilities and deformities. Physical and occupational therapy. Attention to trophic conditions and treatment of enlarged

and painful nerves. Treatment of ocular, buco-pharyngeal, laryngeal and nasal

conditions. Plastic and orthopedic surgery. Relief of reactional conditions in all types of the disease. General attention to the social, psychological and spiritual

environment of the patient.

RESEARCH

Modern research has opened up new avenues of attack against M. leprae. One of these may be the use of antibiotics. The importance of further investigation of chemotherapeutic agents and methods is stressed.

S election of cases.-In therapeutic experiments the following points require special attention. Adequate numbers of moderately advanced lepromatous, lepromin-negative cases should be chosen. They should be cases which have either failed to respond to hydnocarpus or have had no previous treatment.

Tuberculoid, and atypical or intermediate cases, which often

16,2 L eprosy News and Notes 213

show spontaneous remission, should not be included in the evaluation of results.

Minimal therapeutic requirements.-It is considered that the following are the minimal therapeutic requirements in clinical research:

(a) There should be direct or indirect evidence of antibacterial action of the drug against mycobacterial diseases.

(b) The drug must be capable of effective use without causing toxic effects or irreversible physiologic changes.

(c) There must be freedom from undue discomfort when the drug is administered.

(d) There must be acceptable clinical and bacteriological evidence of suppression or regression of the disease; and a visible beginning of this change must be seen within twelve months.

Therapeutic agents needing further investigation.-Injectable sulphones, para-amino salicylic acid, sodium sulphoxylate der ivatives (rongalite), streptomycin, gorli oil, combinations of therapeutic agents, anti-histamine drugs.

Regarding injectable sulphones, attention has been drawn to the possibility that diamino-diphenyl sulphone and its derivatives may become concentrated in certain tissues of the body (for example, the skin, liver, etc.) and that, by giving parenteral medication in the form of subcutaneous injections, satisfactory concentrations of the drug in the blood and skin can be maintained. Investigations should be continued in an endeavor to confirm this finding, and to ascertain whether by means of injections of a suspension of the parent SUbstance, or of emulsions of water-soluble derivatives, a lesser quantity of the drug can be used. If so, the administration of sulphones may be made less costly and thus available to larger numbers of people.

Both para-amino salicylic acid and sodium sulphoxylate (rongalite) appear to be worthy of further research.

While investigations with streptomycin have not as yet been encouraging, it is considered advisable to pursue these inquiries further.

It has been claimed that gorli oil, related to hydnocarpus oil, has a therapeutic effect in leprosy. In view of the importance of this oil in certain parts of Africa, this matter should be further investigated·.

Emphasis has been laid during this Congress on the possible additive effects of combining the suI phones with hydnocarpus


(chaulmoogra) oil or with antibiotics known to be effective against mycobacteria.

As has been pointed out, the administration of the suI phones is liable, in a certain proportion of cases, to result in certain skin reactions of erythema nodosum nature. It has been claimed that certain antihistamine drugs have the property of controling and even aborting these reactions. Should these observations be confirmed, one of the most serious drawbacks to suI phone therapy would be overcome.

CONTROL OF THERAPEUTIC AGENTS .IN LEPROSY

In view of the potential toxic effects of the sulphones, and of the necessity for a carefully regulated schedule of dosage, it is felt that the use of these drugs in leprosy should be subject to careful control. They should be sold only on medical prescription.

It is hoped that the cost of these drugs will be reduced so that they may be made more generally available.

( TERAPEUTICA * INTRODUCCION

Segun las opiniones expresadas en la Conferencia de Rio de Janeiro en 1946 y en el presente Congreso, es evidente que mucho progreso se ha alcanzado en el tratamiento de la lepra desde el Congreso reunido en la ciudad del Cairo .en 1938. Esto progreso se ha obtenido tanto en la neuva terapeutica con los derivados sulf6nicos como en el empleo del aceite de hydnocarpus (chaulmoogra) en altas dosis.

Mientras que la actividad terapeutica de estos medicamentos es evidente, su acci6n sobre el Mycobacterium leprae es relativamente lenta. Se sugiere que se estimule la realizaci6n de nuevas investigaciones con objeto de aumentar la efectividad de estos medicamentos.

Es aconsejable establecer reglas generales con respecto a la administraci6n de los medicamentos de uso aceptado en la terapeutica de la lepra.

DERIVADOS DE DIAMINO-DIFENIL-SULFONA

Se afirma que las drogas del grupo sulf6nico satisfacen las

· The Spanish version of the Committee's report was prepared by a group of its members, and corrected from the final English version by Dr. F. R. Tiant.


condiciones enumeradas bajo el titulo "Requisitos Minimos Terapeuticos" (ver investigacion).

La evidencia existente demuestra que estas drogas son de gran valor en la lepra lepromatosa; y muchos trabajadores consideran que en ese tipo de lepra, es la mejor terapeutica disponible. Su uso en la lepra lepromatosa es por 10 tanto recomendado. Es particularmente efectiva en los casos moderados y avanzados y de gran valor en las lesiones mucosas, nasales, bucofaringeas y laringeas. Las lesiones oculares, frecuentemente mejoran. Su accion se manifiesta en primer termino, por una mejoria del aspecto clinico, siendo la bacteriologica mas lenta en producirse, observandos e entonces modificaciones en la morfologia del Mycobacterium leprae.

Es la opinion de este Congreso que las sulfonas constituyen en el momento actual las drogas de eleccion para el tratamiento de la lepra.

DROGAS SULFONADAS EN usa

Las drogas usadas son, por orden cronologico, promin (promanida), diasona (diamidine) y sulphetrone . .:..-El valor bacteriostatico intrinseco de estas drogas se puede considerar identico, por 10 que son de esperar efectos similares, supuestas las mismas concentraciones tisulares. Faltando suficientes estudios, no es posible hacer afirmaciones dogmaticas respecto a au posologia. En general, se han recomendado las tablas de dosificacion usadas en la tuberculosis. Se sugieren como normas practicas de utilizacion de estas medicaciones las siguientes:

Promin (di-dextrosa sodio sulfonato de la diamino-difenil-sulfona) .-Recomiendase para los adultos, con buen estado general y biometria hematica normal, utilizar como dosis inicial en dovenosamente y por dia, 2 gr. en 5 c.c. de solucion durante una 0 dos semanas. A continuacion, las dosis podran ser elevadas a razon de 1 c.c. diario hasta alcanzar 12% c.c. Las dosis aplicables a los niiios dependen de la edad, peso, tolerancia y estado general. La droga se administrara diariamente durante uno a tres meses seguida de un descanso de una 0 dos semanas despues del cual se recomenzara el t ratamiento. Modificaciones en las dosis y en el tiempo de los periodos de descanso podran ser efectuadas en este esquema, de acuerdo con los factores individuales de los pacientes.

Diasona (sulfoxilato formaldehido disodico de la diaminodifeniI-sulfona) .-Se sugiere la siguiente dosificacion:

la. semana: 1 comprimido, 0.30 gr. al dia durante seis dias y uno de descanso,


2a. semana: .2 comprimidos, 0.60 gr. al dia durante seis dias y uno de descanso,

3a. semana: Tres comprimidos, 0.90 gr. al dia durante seis dias y uno de descanso.

De la 4a. semana en adelante se puede aumentar la dosis hasta el maximum de seis comprimidos diarios, 1.80 gr. si es tolerado. Se permitira un periodo de descanso de una ados semanas despues de cada dos meses de tratamiento.

Sulphetrone (feniIpropiIamino tetrasodio sulfonato de la diamino-difenil-sulfona) .-Esta droga es facilmente soluble y administrable por via oral parenteral. Se recomienda una concentraci6n de 5 mgr. por 100 c.c. de sangre en pacientes de dispensarios. Esta concentraci6n es generalmente obtenida en los adultos con una dosis total diaria de 3 a 6 gr. administrada POl'

via oral. La dosis inicial conveniente es 0.50 gr. cada 8 horas con aumento diario de 0.50 gr. hasta alcanzar la dosis total recomendada. Para los nifios, la dosis apropiada parece ser de 1.50 a 3 gr. diarios. Se administrara la droga continuamente durante seis meses y se permitira entonces un periodo de descanso segun la tolerancia del enfermo.

TOXICIDAD DE LAS DROGAS SULFONADAS

Todos los derivados sulf6nicos son potencialmente hematot6xicos. Producen anemia, que puede aparecer desde el comienzo de su administraci6n. Esta anemia es de grado variable, segun los individuos, y puede obligar a interrumpir la medicaci6n. En la mayoria de los casos, sin embargo, se desarrolla cierto grado de tolerancia y la sangre tiende a volver a la normal. El tratamiento sulf6nico debe ir acompafiado de la administraci6n continua de hierro y complejo de vitamin a B. Tambien deben usarse el extracto hepatico y el cloruro de tiamina.

Algunas manifestaciones de la enfermedad pueden exacerbarse 0 presentarse en el curso de la administraci6n de estos medicamentos. Generalmente consisten en reacciones cutaneas agudas a veces denominadas "eritema nudoso leproso," y tambien en iritis. Estos fen6menos pueden ser motivo para aumentar, disminuir 0 suspender temporalmente la medicaci6n, segun la intensidad de los mismos.

Se pueden observa:r en muy raros casos manifestaciones de sensibilizaci6n a estas drogas. Su incidencia parece ser menor cuando se asocia la terapia vitaminica (complejo B). En caso de presentarse, la droga debe ser suspendida inmediatamente.


CONTROL DE LABORATORIO

En vista de la accion hematot6xica de los derivados sulf6-nicos, es de desar que su uso este sujeto a con troles adecuados de laboratorio. Debe saberse que existen muchas variaciones individuales en la absorci6n y eliminacion de las sulfonas.

A los enfermos en quienes se· so spec he una inadecuada funcion renal deben efectuarse analisis de orina desde el principio del tratamiento y ocasionalmente una determinaci6n de la urea sanguinea.

DERIVADOS DEL ACEITE DE HYDNOCARPUS (CHAULMOOGRA)

Es la opini6n de muchos trabajadores que el aceite de hydnocarpus (chaulmoogra) y sus derivados son efectivos en la lepra lepromatosa y que los maximos beneficios se yen cuando son usados en dosis adecuadas y con regularidad. Los fracasos del aceite de hydnocarpus y sus derivados son amenudo debidos a la clasificacion inadecuada y a la administraci6n irregular. Las preparaciones generalmente usadas son (a) el aceite puro de hydnocarpus con 1/ 2 a 4% de creosota y (b) los esteres etilicos con 1/ 2 a 4% de creosota 0 1/ 2% de iodo.

Cada dia se evidencia mas que los mayores beneficios resultan de la aplicacion de altas dosis (15 a 25 c.c. ala semana) administrados de manera regular e inyectados por las vias subcutaneas intramuscular e intradermica. La dosis maxima usada depende de la tolerancia individual. En algunos casos es posible iniciar el tratamiento con dosis relativamente altas y lIegar hasta 40 o 50 c.c. semanales. Otros pacientes no toleran mas de 10 C.c. y en algunos las dosis maximas deben ser aun inferiores. La tolerancia de los pacientes a veces puede ser mejorada por una regulacion adecuada de las dosis. A este respecto la cali dad del aceite 0 de los esteres tambien es de la mayor importancia.

Es recomendable que las dosis maximas de 15 a 25 C.c. 0

mayores si se considera conveniente, sean alcanzadas en el mayor tiempo posible. Aunque algunas autoridades consideran que se puede llegar a elIas a pesar de los brotes, usualmente se recomienda que cuando estas manifestaciones aparecen, el medicamento debe ser suspendido 0 las dosis reducidas de acuerdo con la intensidad de la reacci6n. De igual manera la disminuci6n 0

suspensi6n del aceite de hydnocarpus (chaulmoogra) puede ser necesaria debido a reacciones locales 0 al aumento de actividad de las lesiones oculares.. Periodos de descanso de 15 dias pueden ser aconsejados despues de tres meses y medio de tratamiento.


MEDIDAS SUPLEMENTARIAS

Seria deplorable si se aceptase que el tratamiento del enfermo de lepra fuera solo a base de los medicamentos arriba mencionados y se omitiese, a titulo de medicacion suplementaria otros procedimientos terapeuticos. Por eso los siguientes se recomiendan de modo especial.

Prevencion y atencion de la invalidez y deformidades. Fisioterapia y laborterapia. Tratamiento de las manifestaciones trOiicas y del dolor en

las neuritis agudas. Tratamiento de las manifestaciones oculares, nasales, buco-

faringeas y laringeas. Cirugia phlstica y ortopedica. Tratamiento de los brotes reaccionales. Consideraci6n general del aspecto psicol6gico, social y espi

ritual del medio ambiente en que vive el paciente.

INVESTIGACION CIENTIFICA

Los estudios medernos han abierto neuvas avenidas de ataque contra el Mycobacterium leprae. Una de estas puede ser el uso de los antibiOticos. Se reitera la importancia de continual' las investigaciones de agentes y metodos terapeuticos.

S eleccion de enferm08.-En los experimentos terapeuticos los siguientes puntos requieren atencion especial. Se escogera un numero suficiente de casos lepromatos moderadamente" avanzados, lepromino-negativos, que no hayan respondido al tratamiento de hydnocarpus 0 que no hayan sido tratados previamente.

En la valoracion de los resultados no deben incluirse los casos tuberculoides y los atipicos e indeterminados que amenudo muestran remisiones expontaneas.

Requerimient08 minim08 terapeutico8.-En la investigacion terapeutica deben cumplirse los siguientes requisitos minimos.

(a) Debe existir evidencia directa 0 indirecta de acci6n antibacteriana de la droga, sobre enfermedades producidas pos mycobacterias.

(b) El medicamento debera poder ser usado efectivamente sin dar lugar a efectos t6xicos ni a lesiones fisiologicas irreversibles.

(c) En su administracion debe dar lugar al minimum de molestias.

(d) Deben haber evidencias tanto clinicas como bacteriologicas de la supresi6n 0 regresi6n de la enfermedad, las cuales


deben comenzar a hacerse visibles dentro del termino de doce meses.

Agentes terapeuticos que necesitan mayor investigaci6n.Sulfonas inyectables, acido para-amino salicilico, derivados del sulfoxilato de sodio (rongalita), estreptomicina, acido gorlico, accion combinada de agentes terapeuticos antihistaminicos.

Con respecto a las sulfonas inyectables se la sugerido la posibilidad de que la diamino-difnil-sulfona y sus derivados puedan concentrarse en ciertos tejidos del cuerpo (por ej., piel, hlgado, etc.) y que se pueda mantener una concentracion satisfactoria del medicamento en sangre y piel, mediante la administraci6n de inyecciones subcutaneas de estos farmacos. Estas investigaciones deben continuarse con el objeto de confirmar los hechos mencionados y determinar si es posible, por medio de inyecciones de una suspensi6n de la sustancia madre 0 de emulsiones de derivados hidrosolubles, el usar una cantidad menor de la droga. Esto haria la administracion de las sulfonas mucho mas barata y mas al alcance de todos los pacientes.

El acido para-amino bezoico y el sulfoxilato de sodio parecen merecer investigaciones ulteriores.

Se considera aconsejable continuar las investigaciones hechas hasta el presente con la estreptomicina, pese a que 10 obtenido no ha sido satisfactorio.

EI aceite de gorli (acido gorlico) que tiene parentesco con el aceite de hydnocarpus se ha preconizado en el tratamiento de la lepra en ciertas partes de Africa donde es muy abundante, por 10 que se aconsejan nuevos estudios.

Mucha importancia se ha dado en este Congreso a la posiblidad de sumar los efectos terapeuticos combinando las sulfonas con el aceite de hydnocarpus (chaulmoogra) 0 con antibi6ticos que se sepa que son efectivos sobre mycobacterias.

Como se ha dicho anteriormente el uso de las sulfonas puede ocasionar en cierto numero de cas os la aparici6n de reacciones cutaneas a tipo eritema nudoso. Se ha reportado que ciertos medicamentos antihistaminicos tienen la propiedad de controlar y aun abortar estos brotes. Si estos trabajos so confirman se salvara uno de los mas serios obstaculos del tratamiento con las sulfonas.

CONTROL DE LOS AGENTES TERAPEUTICOS EN LA LEPRA

En vista de la accion t6xica potencial de los medicamentos sulfonicos y de la necesidad de una dosificacion cuidadosa y met6dica, se considera que el uso de estas drogas en la lepra


debe estar sujeto a un control cuidadoso. Su venta debe ser exclusivamente por receta medica. Es de esperar que el costo de esta droga se reducira para as! ponerlas al alcance de un mayor numero de pacientes.

DISCUSSION

Dr. F ernando Latapi (Mexico): Aunque el dictamen del Comite de Terapeutica refleja las opiniones diversas de los miembros del Congreso, la manera de expresion general es vaga. Debe hacer se una dec lara cion que indique que el Congreso tiene una conviccion: "Que el tratamiento actual de eleccion de la lepra es poria medicacion sulfonica." [Approved.J

Dr. Eduardo Borrell Navarro (Cuba): Agregar el ext. hepatico y el cloruro de tiamina a los medicamentos que deben asociarse al tratamiento por las sulfonas. Que esta Comision recomiende el abaratamiento de estas drogas sulfonicas e insistir de que solo se expendan bajo receta medica. [Approved.J

Dr. Dario Maldonado Romero (Colombia): El senti do dubitativo en que el Congreso recomienda las sulfonas puede dar lugar a que los gobiernos apoyados en ella no quieran apropiar majores presupuestos para adquirir mayores cantidades de sulfonas. [Action?J

Dr. L. M. Bechelli (Brazil): Elogia el trabjo de la Comision de Terapeutica. Sugiere apenas que a respecto de la opinion sobre las sulfonas, sea modificada la frase "algunos investigadores," sustituyendo la por "muchos investigadores."

Dr. A. Peyri (Mexico): Este Congreso no debe olvidar ei valor relativo de los medicamentos como ocurrio con el mercurio, el bismuto el ar., ~nico para la sifilis. Con el chaulmoogra y las sulfonas ocurriria 10 mismo esto es: 1 por 5, por ejemplo.

Dr. C. B. Lara (Philippines): We as physicians, especially those in clinical leprology, would be the last to deny our great debt to empiric methods of investigation as well as to the aid derived from results of investigations in the more exact sciences. For this reason I would suggest that in the report of this Commission there be not given the impression of completeness or finality; that empiric investigations be given some encouragement, provided that some necessary precautions be observed, namely, that a basic knowledge of the disease as well as of the physiologic basis of the remedies to be tested be kept in mind.

Dr. Guillermo Herrera (Dominican Republic): He notado que las sulfonas son tam bien eficaces en la forma llamada tuberculoide. Que el Congreso puede elegir el medicamento de predileccion para combatir Ie lepra.

Dr. Guillermo Basom brio (Argentina): Me llama la atencion en este informe, que hablando del tratamiento sulfonico, dice que "algunos" consideran que es la mejor medicacion en la lepra lepromatosa, mientras que hablando del aceite de chaulmoogra expresa que es la opinion de "muchos trabjadores" que esta droga es igualmente eficaz. Tengo la conviccion de que es consenso general que las sulfonas son superiores al chaulmoogra. Texto espanol pag. 2, linea 7 [mimeographed reportJ que corresponde al capitulo II, donde di-"algunos" poneI' muchos."

Dr. George Brownlee (England) : [In connection with the proposal for:J Control by established centres of treatment with adequate laboratory


facilities. [Add:] In certain countries additional official restrictions may be desirable. [Not approved.]

Dr. N. R. Sloan (Hawaii): No statement has been made on the question of frequency of blood counts in sulfone treatment. Those of us with limited laboratory facilities would like to know: (1) How often should counts be done? (2) What should be included-hemoglobin? red blood cells? total white blood cells? differential? How about recommending that any death under sulfone medication be promptly reported?

Dr. Manuel Santos Silva (Portugal): La Comisi6n de Terapeutica expresa sus conclusiones con prudencia necesaria para evitar entusiasmos exagerados de medicos y enfermos que podrian red un dar en futuras desilusiones. Entre tanto me parece sel' exagerada la referida prudencia visto que me parece ser opini6n general que las sulfonas dan en este momento mejores resultados que los derivados chaulmugricos. [Translated from the Portuguese by the Congress secretariat.]

D1·. Frailano de Mello (Portugal): En la discusi6n de las memorias sobre terapeutica, me pareci6 que habia un conflicto entre sulfonistas y chaulmoogristas. Veo felizmente, que no es asi, y felicito a la Comisi6n por la manera cautelosa, justa y prudente con que reaccion6 frente al debate. El chaulmoogra a pasado su prueba desde hace siglos~ Las sulfonas son un agente moderno, brill ante sin duda, que necesita todavia mas tiempo de experimentaci6n para que sea considerado el medicamento "pOl' excelencia" de la lepra. [Translated from the Portuguese by the Congress secretariat.]

Dr. Jaime Peyri (Spain): En terapeutica de lepra hay tres momentos: (1) Los chancros; terapeutica de Unna con banos locales y astringentes. (2) Granulomas; (a) sulfonas, (b) chaulmugra y arsenicales. (3) Trastornos viserales; los antibi6ticos (Ie estreftomycina y otros) est an cont raindicados .

.,/ EPIDEMIOLOGY AND CONTROL*

INTRODUCTION

The two matters of epidemiology and control of leprosy are treated separately. Nevertheless, they are intimately bound up together in that (a) the discoveries of the one directly influence the other, and conversely; and in that (b) the same person frequently has charge of the execution of programs of epidemiology and of control. With the purpose of clarifying the issues an attempt has been made, as exactly as possible, to delimit both questions.

Epidemiology operates by means of investigations designed to clarify the problems of origin, evolution, and decline of

*The Committee on Epidemiology and Control was composed as follows: Dr. J. A. Doull (Chairman), Dr. C. Manalang (Secretary), Drs. A. Duren and J. Baptiste Risi (Assistant Secretaries), and Drs. E. Agricola, L. M. BechelJi, M. Dalgamouni, M. ,A. Gonzalez Prendes, A. C. Horta, J. R. Innes, C. B. Lara, L. Llano, J. Madeira, V. Martinez Dominquez, J. P. Mota, A. Peyri, A. Rotberg, A. Salamao, and O. Vargas.


leprosy; and also the establishment of endemicity. It attempts to learn the method of transmission of the disease, and all factors which favor or modify transmission.

Control seeks to eradicate the disease, employing all the facts in our possession, looking to epidemiology to furnish more and more these facts.

EPIDEMIOLOGY

GENERAL VIEW

In the introduction to the Epidemiology Report of the Rio de Janeiro Conference the difficulties which are encountered in the epidemiological study of leprosy are recognized.

The disease has great chronicity, an infectious patient remaining so for a long period. There is 'also a prolonged latent period between infection and manifestation of clinical signs.

The disease can not be transmitted to animals, and no method of cultivation of the leprosy bacillus outside the human body is available, thus precluding diagnosis during the latent period.

In the clinical field, skin manifestations must be observed over a period of years. Likewise in the collection of statistical information, such as attack rates in groups of the population varying with respect to some factor of possible significance, data must be collected over a long period of time. This necessitates the use of statistical methods now generally used in the study of other chronic diseases, such as the modified life table method. This method is especially useful in studying attack rates in leprosy households, since it takes account of births and other entrances into the households, and of deaths and other departures.

The primary task of the epidemiologist is to determine the magnitude of the problem in his area and to define it in such terms as will permit of comparison with other areas in his own and other countries. It is obvious, therefore, that there must be common denominators in the recognition and definition of the disease, in classification of its various types, and in the basic data which are collected regarding the individual patient and the general population of which he is a part.

When these elementary conditions are satisfied, and when necessary personnel and funds are available, the epidemiologist should turn to investigation of special topics designed to throw light on the fundamental and yet unknown factors which are responsible for the occurrence and spread of leprosy.


DEFINITION OF TERMS

For the purpose of establishing the frequency of leprosy in age, sex, and racial groups in different countries, and of its respective types, it is essential that the same basic indices and terminology should be used everywhere. Certain suggested indices are therefore appended to this report. Uniformity of data gathered from the whole world will allow of drawing valuable conclusions.

LEPROSY SURVEY

It is proposed that the name "leprosy survey" (in French: "enquete leprologique generale") be given to all the field activities of the epidemiologist. In analysing these activities, we can distinguish several operations, as follows:

(1) A preliminary procedure called a reconnaissance (termed by the Cairo Congress "extensive survey"; in French "prospection") of the region concerned. It consists in determining by rapid investigation, or sampling, if leprosy is present and the degree of its importance.

(2) The principal procedure is the taking of the census. This is the determination of the exact number of patients existing in the region concerned and the proportion in relation to the total population. The person in charge of the census should record a certain minimum of data, even though he may be dealing with rather primitive people. Suggested minimal data are: name or serial number, or both; age; sex; race or tribe; civil status; occupation; clinical type of leprosy.

When available, other data should be added, such as living conditions, bacteriological and immunological findings, and the numbers of children and adults exposed in the household. As suggested by the Rio de Janeiro Conference, the survey can be greatly facilitated by the establishment of permanent "skin dispensaries" and traveling clinics, at which other diseases will also be diagnosed and treated. All leprosy surVeYS should be accompanied by arrangements for treatment of cases discovered, and by a campaign of public education.

(3) A supplementary operation is the special inquiry, or more intensive study of special aspects of leprosy (termed by the Cairo Congress "intensive survey"). These aspects are many, inCluding the relationship of prevalence and of type.: frequency to climate, physiography of the country, ethnology, social conditions, diet, overcrowding, association with insects, tribal customs and coexisting diseases.


CONTROL

Control measures are considered under three divisions: (1) medical measures, (2) legal requirements, and (3) education of the public.

MEDICAL MEASURES

The campaign against leprosy must be undertaken by the coordinated action of three basic organizations: (1) leprosaria, (2) dispensaries or out-patient clinics, and (3) preventoria.

(1) L eprosaria.-A leprosarium is a place for isolation of (a) infectious patients, and (b) non-infectious patients for social, economic or other reasons. Services (medical, social, etc.) rendered to the patients should be complete and free of charge.

The most satisfactory type of leprosarium is the agricultural colon}", where the patients may engage in agricultural and animal-raising activities.

Another type of leprosarium to be recommended is that established on a sanatorium basis for patients with personal resources. Such patients should be subject to the same rules of prophylaxis as the nonpaying patients in the colony-leprosarium. The sanatorium may be of either governmental or private ownership, but in any case must be subject to the control of the official leprosy service.

It is recommended that the leprosarium should be situated in the proximity of an urban center with easy means of communications. Preferably it should be within a radius of 10 to 30 km. from the nearest city. The isolation of patients on special islands is categorically condemned.

The site should be selected with a view not only to the proper functioning of the institution but also to the material and moral welfare of the inmates. The. leprosarium of the colony type should be located in a place which lends itself, because of the soil and other natural resources, to the development of agricultural and pastoral activities. It should, when possible, be of regional character, and with a capacity of not more than 1,000 patients.

In its organization the leprosarium should have three zones: (1) healthy zone, (2) intermediate zone, (3) patients' zone. It is recommended that there should be' a minimum of one physician for every 200 patients.

Besides institutional isolation, home isolation may be permitted provided it can be guaranteed that isolation and prophy-


laxis will be adequate. Private isolation should not be permitted in apartment, business, or industrial buildings.

(2) Dispensaries or outpatient clinics.-Dispensaries or outpatients clinics are of fundamental importance for the control of leprosy. They should be regional and located in areas of greatest density of population, with suitable communication facilities. They shouldl be adequafely provided with personnel, material, and means of transportation in order to fulfill their purposes, which are:

(a) finding of cases and segregation of infectious ones; ( b) epidemiological investigations; (c) selection of cases for isolation; (d) control and treatment of non-isolated cases, including

those paroled from leprosaria; (e) control of suspects; (f) control of contacts; (g) control of absconders; (h) removal to preventoria of children of infectious parents

when necessary; (i) sanitary education; (j) disposal of cases for final discharge.

The control of contacts should be carried out in accordance with modern concepts, with special reference to the lepromin reaction. On that basis, contacts should be carried out in accordance with modern concepts, with special reference to the lepromin reaction. On that basis, contacts should be divided into two groups: lepromin negative and lepromin positive.

Contacts with negative and weakly-positive lepromin reactions should be given special attention. They should be reexamined every six months for five years, counting from the last known contact, however slight, with an infectious case.

Contacts giving strongly positive lepromin reactions may be re-examined at longer intervals, and the period of observation may be decreased at the discretion of the health authorities.

(3) Preventoria.-The preventorium is designed to care for the minor dependents of patients under isolation. By preference, it should be located within a city or in its immediate vicinity. This will facilitate the functioning of the institution, the provision of efficient medical and sanitary services, and progressive adaptation of the inmates to society.

Modern clinical and immunological concepts of leprosy indicate that children with' the bacteriologically-negative tuberculoid and indeterminate forms may be permitted to remain in


the preventorium; likewise lepromin-positive children paroled from leprosaria. It is recommended, however, that this concession be granted only in institutions where medical control is regular and efficient.

Separate from the pavilions housing the ordinary inmates, there should be an observation pavilion for suspects and cases such as those mentioned above. It is also recommended that recently admitted children be accommodated in a special ward for a period of not less than three weeks.

Children living in the preventorium should be submitted to periodical examinations, the duration and frequency of which would depend on their state of resistance as indicated by the lepromin reactions.

The institution should have a nursery for the care of the newlyborn infants of leprosy patients. This section might be located in the preventorium itself, or outside of it.

PREPARATION OF TECHNICAL PERSONNEL

It should be emphasized that it is not possible to develop a campaign against leprosy without specially trained technical personnel. It is recommended that physicians, nurses, laboratory technicians and attendants should be given courses of leprology and practical training in the leprosy-control services or establishments. To official institutions for the control of leprosy it is also recommended that the category of leprologist should be created, with adequate remuneration, as a necessary incentive to the attainment of technical efficiency.

In countries where leprosy is endemic, it is of the greatest importance that the teaching of leprology in the dermatological clinics should be emphasized. It should also be included in public health courses.

Governments should maintain, or aid, the operation of institutes of leprology dedicated to scientific investigations in the epidemiology, therapy and pathology of leprosy, as well as the proper training of technical personnel.

LEGAL REQUIREMENTS

General recommendation.-Laws for the control of leprosy enacted by legislative bodies should embody only general principles and the necessary authorizations. The regulations to be established should be made by experts, and should be revised periodically in accord with the progress of epidemiological knowledge.

Specific recommendations.-(a) In all countries where lep-


rosy is endemic, medical students should be given adequate instructions regarding the disease, to provide for its early diagnosis and notification.

(b) Governments should initiate the necessary investigations to acquire as complete a knowledge as possible of the number of leprosy patients, this being an indispensable basis for prophylaxis.

(c) Infective cases of leprosy should be isolated. The mode and duration of isolation will vary, depending upon the clinical and social conditions of the patient and special local conditions.

(d) Wherever possible, adequate treatment should be provided for all cases, whether isolated or not.

( e) Governments are strongly urged to provide, for isolated patients, the standards of comfort and amenities to which they are entitled. They should be given opportunities to improve th"eir condition by their own work, or to use their own resources.

(f) Governments are urged to provide, directly or indirectly, the necessary means of subsistence for non-self-suppor ting dependents of leprosy patients.

(g) Recognising that bad hygienic conditions of housing and living in large communities contribute to the spread of leprosy, governments are recommended to make all possible efforts to improve such conditions, in accordance with local possibilities. .

(h) Non-infectious patients, not isolated, should be kept under regular and periodic supervision.

(i) Regular and periodic observation is also of t.he utmost importance for those who are or have been in direct contact with patients.

(j) Separation of children from infective patients should be made immediately after birth, or as soon as the diagnosis of leprosy in the parent or the person who is "in loco parentis" is made.

(k) For the termination of isolation of infective cases and the supervision of non-isolated cases the clinical, bacteriological and immunological conditions should be taken into account. In the supervision of contacts, immunological conditions should be taken into account.

(l) Propaganda for non-scientific remedies by interested persons represent a serious impediment to the control of leprosy and should be curtailed by governments.

(m) It is recommended that co-operative agreements be made between neighboring governments for the interchange of


information designed to permit the continuance of supervision of patients and contacts and the prevention of the illegal passage of patients from one country to another.

EDUCATION OF THE GENERAL PUBLIC

For educational purposes the public may be divided into three classes: (1) the general public, (2) the selected public, and (3) contacts of leprosy patients.

Propaganda should be carried on through the press, radio, leaflets, etc., referring to the advantage of the examination of everyone with skin diseases or with disturbances of cutaneous sensation. The examinations should be made in public dermatology clinics or in private offices of dermatologists. The same propaganda should stress the danger of consulting, because of fear and prejudice towards their disease, quacks, or unlicensed doctors; also of using patent medicines, etc., which may prove harmful.

It should be emphasized that leprosy is infectious and contagious, but avoidable. Its control involves precautions and restrictions which vary in different regions, but need not be excessive. Only "open" cases require isolation. The period of isolation depends upon the progress of the disease .and its response to treatment. Leprosy is frequently curable and most likely to be so if treated early, provided the treatment is supervised by adequately trained physicians and is taken regularly by the patients. Modern drugs promise to be more effective than those available in the past.

It is necessary for the educational campaign to secure the help of different organizations which influence public opinion, such as professional, civic, religious and missionary organizations, press associations and organizations of authors, the radio broadcasting and moving-picture industries, etc. The essential points to bring out are:

(a) To avoid the use of the word "leper" and other undesirable terms;

(b) To correct the present error of public opinion that leprosy is a Biblical scourge and that the patient is cursed. This error brings stigma and injury to the patient, makes him conceal his disease and prevents him from seeking medical assistance, and increases the danger to the public.

(c) We deprecate all publicity in newspapers, magazines, novels, movies, etc., and all other situations in which leprosy and the patient are dramatized, when the presentation does not agree with modern knowledge.


Household contacts should receive instruction regarding the nature of the disease, stressing particularly:

(a) the advantages of an early general medical examination;

(b) the advantages of successive and periodical examinations;

(c) the importance of personal and household hygiene.

APPENDIX 1. RECOMMENDED INDICES

1. THE MORBIDITY PREVALENCE RATE OR PREVALENCE INDEX

This rate should be as recommended by the Rio de Janeiro Conference, viz: The numer of cases of leprosy existing in a population at a specific date:

Number of cases of leprosy X 1000 M. P. R.= ---- ---------

Total enumerated population.

2. THE MORBIDITY INCIDENCE RATE OR INCIDENCE INDEX

This index is required to learn the trend of the disease. In areas where the census is repeated, it will be possible to compute an estimated annual incidence rate; that is, the number of new cases appearing in the population during a period of one year:

Number of new cases in a year X 1000 Annual M. I. R. = ---------------

Total enumerated population.

Note: Wherever it is possible to classify the cases according to type, both the M. P. R. and the M. 1. R. should be broken down (subdivided) by type of the disease. In calculating the rates for specific types, the denominator should be as for total prevalence and incidence; that is, the total enumerated population of the area, village, city or country.

It will be noted that if the average duration of the disease, between recognition and death, is for example ten years, and if the total prevalence of the disease is five per 1000, we must have an average annual incidence (M. 1. R.) of five per 10,000:

Prevalence = incidence X duration (years) 5 5

or -- = -- X 10 1000 10000

It will also be noted that, if the repeated censuses are fairly accurate, the duration of the disease may be estimated from the M. P. R. and the M. 1. R. because:

230 I ntel'national Journal of Leprosy

Prevalence Duration = ---_

Incidence

3. THE CHILDHOOD RATES

1948

(a) The prevalence rate for children (childhood prevalence rate) recommended by the Rio de Janeiro Conference should be adopted, viz:

The number of cases in children under 15 years of age X 1000

The number of enumerated children under 15 years of age

(b) Likewise, when censuses are repeated, the annual childhood incidence rate, which is most important, should be estimated, viz:

The number of new cases in children under 15 yrs. of age X 1000

The number of enumerated children under 15 years of age

Note: It is desirable to break down (subdivide) prevalence and incidence rates in children by sex and type.

4. THE ADULT RATES

( a) Prevalence:

Number of cases in persons over 15 years of age X 1000

Number of enumerated persons over 15 years of age

(b) Incidence:

Number of new cases in persons over 15 years of age X 100

Number of enumerated persons over 15 years of age

Note: It is desirable to break down both prevalence and incidence rates by sex and type.

5. HOUSEHOLD CONTACT RATES

Similarly, prevalence and incidence rates for children 0 to 15 years of age and for adults 15 years and more may be obtained in special long-time studies for persons exposed in the household to different types of leprosy. The difficulties of accurate studies of this type are recognized, and the advantages of the modified life table method are emphasized.

APPENDIX II. RESOLUTION

Proposed by the Committee on Epidemiology and Control that the Congress give recognition to the importance of en-


forcing laws dealing with national campaigns against leprosy; express commendation to Colombia, Egypt, Portugal and Norway for having accomplished this in recent years; and resolve that these regulations should be published in the Transactions of the Congress.

[This resolution, submitted se{!arately, did not find its way into the Committee report as presented at the Plenary Session and consequently was not acted upon.]

( EPIDEMILOGIA Y CONTROL*

INTRODUCCION

En este reporte se discuten separadamente la epidemiologia y el control de la lepra. Sin embargo, estas materias estan intimamente entrelazadas pol' dos motivos: (1) porque los descubrimientos de una influyen directamente la otra y recfprocamente, y (2) porque, frecuentemente, las mismas personas u organismos estan encargados de la ejecuci6n de las programas de epidemiologia y control. Con el fin de aclarar los conceptos, se ha intentado, de la manera mas exacta posible, de delimitar ambas cuestiones.

La Epidemiologia, opera POI' medio de investigaciones encaminadas a aclarar los problemas del origen, evolucion y declinacion de la lepra, asi como determinar su endemicidad; trata tambien de conocer el medio de trasmision de la enfermedad y todos los factores que modifican 0 favorecen dicha trasmisi6n.

El Control persigue la erradicacion de la enformedad empleando todos los medios a nuestro alcance, aprovichando todos los datos que la Epidemiologia Ie ofrece.

EPIDEMIOLOGIA

GENERALIDADES

En la Introducci6n al reporte 0 ponencia sobre Epidemiologia de la Conferencia de Rio de Janeiro se reconocen las dificultades que se encuentran en el estudio epidemiologico de la lepra.

La enfermedad tiene una gran cronicidad, de manera que el enfermo permanece infectante durante largo tiempo. Existe tambi€m un prolongado ~rfodo de latencia entre el momento de la infeccion y la manifestaci6n de signos clfnicos.

La enfermedad no puede ser trasmitida a los animales y no

*The Spanish version of the committee's report was prepared by Dr. Luis Rodriguez Plasencia from the final English,version.

232 International Journal of L eprosy 1948

tenemos ningun metodo de cultivo del bacilo de la lepra, 10 cual nos impide el diagn6stico durante el periodo de latencia.

Clinicamente, las manifestaciones cutaneas deben ser observadas durante un numero de afios, y, de la misma manera, para obtener informacion estadistica tal como, por ejemplo, el indice de morbilidad en relaci6n con algun factor de posible importancia, se hace necasario reunir datos durante un largo periodo de tiempo. Esto requiere el empleo de metod os en uso actualmente en el estudio de otras enformedades cronicas, tal como el metodo de la tabla modificada de vida (modified life table method). Este sistema es especial mente util en el estudio del indice de morbilidad en hogares leprosos, pues tiene en cuenta los nacimientos y otras formas de ingreso en el hogar, asi como las muertes y otras formas de egreso.

La misi6n primordial del epidemi610go es determinar la magnitud del problema en el area a su cuidado, definiendolo en tales terminos que permita la comparacion con otros territorios de su propio pais y aun del extranjero. Resulta obvio, por 10 tanto, que deben existir comunes denominadores en el reconocimiento y definicion de la enfermedad, en la clasificacion de sus diferentes tipos y en los datos basicos que se reunen con relacion al paciente individual y a la poblacion general a la cual pertenece.

Estando satisfechas estas condiciones elementales y cuando se dispone del personal y los fondos necesarios, el epidemiologo debe dedicarse a la investigacion de cuestiones especiales encaminadas a iluminar los factores fundamentales, y todavia oscuros, responsables de la existencia y de la diseminaci6n de la lepra.

DEFINICION DE ALGUNOS TERMINOS

Para determinar la incidencia de la lepra segun la edad, el sexo y la raza en diferentes paises, es esencial que en todas partes se usen la misma terminologia y los mismos indices. En este reporte se sugieren ciertos indices, ya que la uniformidad de datos reunidos en el mundo entero permitira llegar a valiosas conclusiones.

CENSO DE LA LEPRA (LEPROSY SURVEY)

Se propone este nombre (en frances: enquete leprologique generale) para todas las actividades de campo a cargo del epidemiologo. Al analizar estas actividades, podemos distinguir diversas operaciones, a saber:

(1) Un procedimiento preliminar de "reconnaissance"


Hamado censo extensivo (extensive survey; en frances: prospection) de la region estudiada. Consiste en determinar, por investigacion rapida, si la lepra existe y el grado de su importancia.

(2) El procedimiento principal es el censo propiamente ducho (census), 0 sea, la determinacion del numero exacto de pacientes en la region y su proporcion en relacion con la poblacion general. La persona a cargo de este censo debe reunir un minimum de datos, sun cuando trabaja con poblaciones primitivas en cuanto a civilizacion. Se sugiere el minimum siguiente: nombre 0 numero de serie, 0 ambos; edad; sexo; raza o tribu; estado civil, ocupacion, y tipo clinico de lepra.

Cuando sea posible, deben anadirse otros datos tales como condiciones 0 "standard" de vida, estado inmunologico, basterioscopia, asi como el numero de menores y adultos convivientes con el enfermo y expuestos al contagio. Segun se sugirio en Rio de Janeiro, el cenSQ se facilita grandemente con el establecimiento de dispensarios dermatologicos permanentes y clinicas ambulantes, en los cuales se diagnostiquen 0 traten tambien otras enfermedades. Todo censo de lepra debe ir acompanado del establecimiento de posibilidades de tratamiento para los casos nuevos que se descubran y de una compana de educaci6n publica sobre la materia.

(3) La indagaci6n especial (special inquiry), Hamada en el Congreso del Cairo "intensive survey" es una operacion suplementaria para un estudio mas intensivo de determinados aspectos de la lepra. Estos son muchos, inluyendo la relacion entre la incidencia y la frecuencia de cada tipo por una parte, y, por otra, el clima, fisiografia del pais etnologia, condiciones sociales, dieta, hecinamiento, insectos, costumbres y enfermedades coexistentes.

CONTROL

Las medidas encaminadas a lograr el control de la lepra se consideran divididas en tres categorias: (1) medidas de 6rden medico, (2) medidas de orden legal, y (3) educacion del publico.

MEDIDAS DE ORDEN MEDICO

La campana contra la lepra debe emprenderse por medio _ de la acci6n coordinanda de tre~ organizaciones fundamentales: los leprosarios, los dispensarios para pacientes ambulatorios y los preventorios.

(1) Leprosarios.-Un leprosario, leprosorio, leproseria 0

leprocomio es un lugar para el aislamiento de (a) los enfermos

234 International J ournal of Leprosy 1948

infectantes y (b) enfermos no-infectantes, por razones sociales, economlcas u otras. Los servicios que reciban los pacientes,sociales, medicos, etc.-deben ser completos y gratuitos.

El tipo de leprosario mas satisfactorio es la colonia agricola en la cual los enfermos puedan ocuparse en actividades agropecuarias diversas.

Otro tipo de leprosario recomendable es el sanatorial, para pacientes con recursos economicos. Tales enfermos deben estar sujetos a las mismas reglas de profilaxis que los del leprosario tipo colonia. Este sanatorio puede ser de propiedad privada 0

gubernamental, pero, en todo caso, debe estar sometido al control de la autoridad oficial encargada de la lucha anti-leprosa.

Se recomienda que los leprosario"s deben estar situados en la proximidad de un centro urbano con faciles medios de comunicacion. Preferiblemente deben estar a una distancia entre 10 y 30 Kms. de la ciudad mas cercana. Se condena especialmente el aislamiento de los enfermos en islas.

La seleccion del sitio debe hacerse con vistas, no solo al buen funcionamiento de la institucion, sino tambien al bienestar moral y material de los pacientes. Elleprosario del tipo colonia debe estal' situado en un lugar que se preste, por sus condiciones naturales, al desarrollo de actividades pastorales y agricolas; debe sel' de cal'acter regional y no albergar mas de 1,000 enfermos.

En su organizacion el leprosario debe tener tres zonas: (1) la zona sana, (2) la intermedia, y (3) la zona de los pacientes. Se recomienda que haya un minimum de un medico por cada 200 enfermos.

Ademas del aislamiento institucional, se debe permitir el aislamiento en el domicilio, siempre y cuando se garantice que el aislamiento y la profilaxis seran las adecuadas. Nose debe permitir el aislamiento en eficicios de oficinas, de apartamientos o industiales.

(2) Dispensarios para enfermos ambulatorios.-Los dispensarios, cllnicas 0 consultas externas son de una importancia · fundamental para el control de la lepra. Deben de ser de caracter regional y estar situ ados en las areas de mayor densidad de poblacion, con facilidades de comunicacion adecuadas. Deben estar provistos de personal, materia] y medios de transporte para poder cumplir sus fines, los cuales son:

(a) hallaggo de casos y separacion de los infectantes, (b) investigaciones epidemiologicas,


(c) seleccion de los casos para aislamiento, (d) control y tratamiento de los casos no aislados, inclu

yendo aquellos en observaci6n procedentes de los leprosarios,

( e) control de los sospechosos, (f) control de los convivientes . (contacts), (g) control de los fugitivos, (h) ingresar en los preventorios, cuando sea necesario, los

hijos, de padres contagiantes, (i) la educacion sanataria, (j) el "alta" final de los casos.

El control de los contactos debe llevarse a cabo de acuerdo con los conceptos modern os, especialmente en cuonto se refiere a la reaccion a Ie lepromina. Consecuentemente, los convivientes 0 contactos deben dividirse en dos grupos: positivos a la lepromina y negativos a la lepromina.

Aquellos con reacciones negativas 0 debilmente positivas deberan ser objeto de antencion especial, examinandoseles cada seis meses, durante cinco afios a contar desde el ultimo contacto conocido, aunque sea ligero, con un caso infeccioso.

Los convivientes 0 contactos con reacciones a la lepromina fuertemente positivas pueden ser examinados a intervalos mas largos, disminuyendose el periodo de observacion de acuerdo con el criterio de la autoridad sanitaria competente.

(3) Preventorios.-El objeto del preventorio es el cuidado de los menores dependientes de enfermos en aislamiento. De preferencia deben estar situados dentro de una ciudad 0 en su inmediata vecindad, 10 cual facilitara el funcionamiento de la institucion, la obtencion de personal medico eficiente y la adaptacion progresiva de los intern ados al medio social ambiente.

Los conceptos cllnicos e inmunologicos modern os indican que los nifios con formas indeterminadas y tuberculoides bacteriologicamente negativas pueden permanacer en los preventorios, as! como aquellos, positivos a la lepromina, en observacion procedentes de los leprosarios ("on parole"). Se recomienda que est a concesion se Ie haga solo en aquellas instituciones con un control medico mas eficiente.

Separado de los pabellones de los asilados ordinarios, debe haber un pabellon de observacion para los casos sospechosos y para aqueHos mencionados en el parrafo anterior. Se recomienda tambien que los nifios de nuevo ingreso sean instalados en una sala especial por un periodo no menor de tres semanas.

Todos los menores del preventorio deben ser examinados


peri6dicamente, dependiendo la frecuencia de los examenes de su estado de resistencia indicado por la reaccion a la lepromina.

La instituci6n debe tener un departamento ("nursery") para los reci€m-nacidos y lactantes hijos de enfermos de lepra, el cual pod ria estar situado dentro del preventorio 0 fuera de ek.

PREPARACION DEL PERSONAL TECNICO

Se debe insistir en que no es posible desarrollar una campana contra la lepra sin un personal tecnico especialmente entrenado. Se recomienda que los medicos, enfermeras, tecnicos de laboratorio y sirvientes reciban cursos de leprologia y un entrenamiento practico en los servicios 0 establecimientos de control de la lepra. En cuanto a las instituciones oficiales, se recomienda la creaci6n de los cargos de leprologo, con adecuada remuneracion como incentivo necesario para alcanzar la eficiencia tecnica· requerida.

En los paises con lepra endemica es de la mayor importancia que en las clinicas y consultas dermatolo16gicas se insista en la ensenanza de la leprologia, la cual debe estar includia tambien en los cursos de especializacion sanitaria.

Los gobiernos deb en mantener 0 prestar ayuda a los institutos de leprologia dedicados a la investigaci6n cientifica sobre epidemiologia, terapeutica y anatomia patol6gica de la lepra, as! como propender al adecuado entrenamiento del personal tecnico.

MEDIDAS DE ORDEN LEGAL

R ecomendaci6n general. Las leyes para el control de la lepra votadas POl' cuerpos

legislativos deben incluir solo principios de orden general y las necesarias autorizaciones. Las ordenanzas 0 reglas deben ser hechas POl'S expertos, revisandose peri6dicamente de acuerdo con los progresos de los conocimientos de epidemiologia.

Recomendaciones especificas. (a) En los paises con endemia leprosa, los estudiantes de

medicina deben recibir una ensenanza adecuada en relaci6n con la enfermedad, dotandolos de capacidad para un diagnostico precoz de la misma.

(b) Los gobiernos deben iniciar las necesarias investigaciones para adquirir un conocimiento 10 mas completo posible del numero de enfermos de lepra, 10 que constituye un paso previo indispensable para una buena campana de profilaxis.

(c) Los casos infectantes deben ser aislados. La forma y duraci6n del aislamiento variaran de acuerdo con las condiciones clfnicas y sociales del enfermo y de la localidad.

16,2 Leprosy N ews and Notes 237

(d) Cuando sea posible, se proveenl. un tratamiento adecuado para todos los casos, aislados 0 no.

( e) Se solicita enfaticamente de los gobiernos que provean a los pacientes aislados de todas las comodidades y amenidades a que ellos tienen derecho. Se les debe dar oportunidades para mejorar su situacion utilizando sus propios medios y facultades.

(f) Se solicita de los Gobiernos que provean, directa 0

indirectamente, los necesarios medios de subsistencia para aquellos dependientes de enfermos de lepra incapaces de mantenerse POl' si mismos.

(g) Reconociendo que las condiciones de vida y albergue defectuosas, en las grandes poblaciones, contribuyen a la diseminaci6n de la lepra, se urge a los gobiernos que hagan todos los esfuerzos posibles para mejorar esta situaci6n de acuerdo con las posibilidades locales.

(h) Los enfermos no infectantes, no aislados, deben mantenerse bajo supervision regular y peri6dica.

(i) La observaci6n peri6dica y regular es tambien de la mayor importancia en aquellos que estan 0 han estado en contacto con enfermos.

(j) La separaci6n de los hijos de pacientes contagiosos debe realizarse inmediatamente despues del nacimiento 0 tan pronto como el diagnostico de lepra se establezca en el padre 0 en la persona "in loco parentis."

(k) Para la terminacion del aislamiento de los casos infectantes y para la supervisi6n de los cas os ambulatorios se debe tener en cuenta los datos inmunol6gicos y bacteriologicos. EI estado inmunol6gico debe regir la conducta a seguir con los convivientes 0 contactos.

(l) La propaganda de remedios no cientificos constituye un serio impedimento para el control de la lepra y los gobiernos deben tomar medidas en contra de esta practica.

(m) Se recomienda que POI' las gobiernos de paises vecinos se tom en acuerdos cooperartivos para el inteccambio de informacion encaminada a permitir la continuidad de la observaci6n de los enfermos y convivientes y evitar el paso ilegal de enfermos de un pais a otro.

EDUCACION DEL PUBLICO

En cuanto a los fines educativos, el publico puede dividirse en tres grupos: (1) el publico general, (2) el publico selecto y (3) los convivientes 0 contactos de enfermos .

. La propaganda debe 'llevarse a cabo porIa prensa, el radio, folletos, etc., divulgando la ventaja del examen de todo el que

238 International Journal of L eprosy 1948

tenga una enfermedad de la piel 0 trastornos de la sensibilidad cutanea. Estos' examenes deben hacerse en hospitales publicos dermatol6gicos 0 en las consultas privadas de los dermatologos, a causa del temor y prejuicio hacia su enfermedad. Esta propaganda debe hacer enfasis sobre el peligro de consultar charlatanes 0 curanderos y de tomar remedios caseros que pueden ser daninos.

Debe insistirse en que Ia lepra es infecciosa y contagiosa, pero evitable. Su control requiere precauciones y restricciones que varian segun las distintas regiones, pero que no necesitan ser excesivas. S6lo los casos abiertos necesitan aislamiento. EI periodo de aislamiento depende del avance de la enfermedad y de su respuesta al tratamiento. La lepra es frecuentemente curable y es 10 mas probable que asi suceda si se Ie trata precozmente por medicos entrenados y con la regularidad necesaria. Las drogas modernas prometen ser mas efectivas que las usadas en el pasado.

Para Ia campana educativa es necesario obtener el auxilio de distintas organizaciones con influencia en la opinion publica, como asociaciones civicas, profesionales, religiosas, etc., las empresas de radio-difusion, teatrales y cinematografi~as. Lo& puntos escenciales que hay que destacar son:

(a) Evitar el uso de la palabra "leproso" 0 cualquier otro termino indeseable.

( b) Enmendar la creencia popular de que la lepra es un azote 0 castigo y que el enfermo esta maldito. Esta creencia dana y estigmatiza al enfermo, haciendolo ocultar su enfermedad y Ie imp ide solicitar auxilio medico, aumentandose el peligro para el publico.

(c) Condenamos toda publici dad en periodicos, revistas, novelas, peliculas, etc., en los cuales la lepra y los enfermos se dramatizan, cuando la presentacion no esta de acuerdo con la realidad cientifica.

Los convicientes deben recibir instrucci6n en relacion con la verdadera naturaleza de la afecci6n, insistiendo particularmente sobre:

(a) las ventajas de un examen medico general precoz; (b) la conveniencia de examenes periodicos sucesivos, y (c) la importancia de la higiene personal y domestica.


APENDICE. INDICES QUE SE RECOMIENDAN

1. INDICE DE PREVALENCIA (MORBIDITY PREVALENCE RATE)

Este indice se obtiene en la forma recomendada en la Conferencia de Rio de Janeiro, es decir: dividiendo, el numero de casos conocidos multiplicados por mil, entre la cifra total de poblaci6n enumerada.

Numero de enfermos X 1000 1. de P. = -----------

Poblacion total enumerada

2. I N DICE DE I NCIDENCIA (MORBIDITY I NCIDENCE RATE)

Este indice nos da a conocer la marcha 0 tendencia general de la endemia. En regiones donde los censos se repiten sera posible computar un indice aproximado anual de la incidencia de la enfermedad, esto es, el numero de casos nuevos que aparecen durante el ano:

Cas os nuevos en el ano X 1000 1. de 1. anual = -----______ _

Poblacion total enumerada

N ota.-Cuando sea posible clasificar los casos de acuerdo con el tipo de la enfermedad, tanto el indice de prevalencia como el de incidencia deben subdividirse segun dichos tipos. Al calcular las proporciones en los tipos especificos, el denominador debe ser igual que cuando se calculan la prevalencia 0 incidencia totales, 0 sea, la poblacion total enumerada en el area, region, pueblo ciudad 0 pais.

Se notara que si el promedio de duraci6n de la enfermedad, entre el diagnostico y la muerte, es, por ejemplo, diez anos, Y la prevalencia total es de un 5 por mil, debemos tener una incidencia anual promedio de 5 por diez mil:

5 5 X 10

1000 10000

P revalencia = Incidencia X Duracion en anos

Se notara tambien que, si los censos repetidos son bastante exactos, la duracion de la enfermedad puede estimarse a partir de los indices de prevalencia e incidencia, ya que:

Prevalencia Dumcion = - - - - -

Incidencia


3. INDICES EN LA INFANCIA

(a) Debe adoptarse el indice de prevalencia para nifios recomendado en la Conferencia de Rio, es decir:

Numero de enfermos menores de 15 alios X 1000 ------------------------------------------=X Numero total de habitantes enumerados de la misma edad

(b) De la misma manera, cuando se repiten los censos, la incidencia anual en nifios, que es de la mayor importancia, se obtiene ne la forma siguiente:

Numero de casos nuevos menores de 15 alios en el alio X 1000 ---------------------------------------------=X Numero total de habitantes enumerados de la misma edad

Nota.--Es deseable subdividir los indices de prevalencia e incidencia en los nifios, de acuerdo con el sexo y el tipo.

4. INDICES EN EL ADULTO

(a) Prevalencia :

Numero de enfermos mayores de 15 alios X 1000 X

Numero total de habitantes enumerados de la misma edad

(b) Incidencia:

Numero de casos nuevos en el aiio, mayores de 15 aiios X 1000

Total de poblaci6n enumerados de la misma edad

N ota.-Es deseable subdividir ambos indices de acuerdo con el sexo y el tipo de la enfermedad.

5. INDICES EN LOS CONVIVIENTES ("CONTACTS")

Similarmente, amhos indices, para menores y mayo res de 15 afios, pueden obtenerse en estudios especiales sobre aquellas personas (convivientes) que han estado en contacto con enfermos de los distintos tip os de lepra, ya sea en el hogar 0

fuera de el. Se admiten grandes dificultades para realizar estudios exactos de este tipo, haciendose hincapie en la utili dad del metodo de la tabla modificada de vida ("modified life table method") .

APENDICE II. RESOLUCION

Propuesta por el Comite sobre Epidemiologia y Control, que el Congreso reconozco la importancia de la actualizacion de las leyes normativas de las campafias nacionales de profilaxis de la lepra; hacer mencion comendatoria de la Republica de Co-


lombia, Egipto, Portugal y Noruega por haber realizado esto en los dos ultimos alios; y resuelve que estos reglamentos sean publicados en la Memoria del Congreso.

[Esta resoluci6n, presentada separadamente, n6 fue incluida en el informe del Comite segun presentado en la Sesi6n Plenaria, y por consiguiente no se Ie tom6 en consideraci6n.]

DISCUSSION

Dr. T. F. Davey (Nigeria): It is to be regretted that no reference is made to community isolation in villages. This is a form of isolation which has proved successful when based on a leprosarium, and which offers probably the only practical means of inducing large scale isolation in tropical Africa, a highly endemic area where it is impossible to build large numbers of leprosaria.

Dr. A. Peyri (Mexico) and Dr. Leonidas Llano (Argentina): Al objeto de obtenar el plano catastral del mundo, se recomienda a los gobiernos que por intermedio de sus autoridades sanitarias hagan censos quincenales en todos los paises, segUn zonas leprogenas y estaciones. Al objeto de uniformar los datos quinquenios se haran dell al 5 y del 6 al 10 de cada decenio. Estos censos se remitiran en al ano subsiguiente al International Leprosy Association para su publicacion.

Dr. C. J. Austin (Fiji): I move the deletion of the following sentence under "Leprosaria": "The Committee reiterates the formal condemnation, already stated, of isolation of patients on special islands."

Dr. Francisco Garcia Ramos (Mexico): Propongo que toda "instituciones de leprologia," en su secci6n de "epidemiologia," debe constar con un puesto obligatorio de "Investigador Cientifico" sobre los problemas oscuros de bacteriologia, inoculaciones, cultivos, etc.

Dr. M. Dalgamouni (Egypt): I wish to move an amendment to the statement under Medical Measures: "The most satisfactory type of leprosarium is one in which the patients are actively encouraged to engage in agricultural work of every variety, in other occupations, and in educational activities. Advantage should be taken of the prolonged stay of the patients in the colony, and of the talents they may have, to arrange for general, occupational and agricultural education under the guidance of experts, so that such leprosaria may become centers of enlightenment instead of refuges for the destitute and the lazy." Services (medical and social) should only be rendered in those cases when the patients cannot ....

Dr. E. R. Kellersberger (U. S. A.) : After a world experience in seeing and studying some hundreds of leprosy colonies, I believe that the policy of using isolated islands, not easily accessible, for the isolation and treatment of patients with leprosy is in general a failure and should be discontinued.

Dr. Hugo Pesce (Peru): [Referring to section (C), Control:] Anteponer al resto del texto: "Se declara conveniente que en cada naci6n las atribuciones de direcci6n y orientaci6n de la lucha antileprosa sean conferidas a un organismo especifico de la Sanidad (Departamento de Lepra o Servicio Antileproso 0 otras designaciones)".

Drs. L. M. Bechelli and A. Rothberg (Brazil): Recomendamos que os casos tubercul6ides e indeterminados nao contagiontes, especialmente os


lepromino positivo, nao sejam fichados como doentes de lepra mas apenas como "casos em observacao," assim permanesendo sob controle e tratamento, ate que se possa cancelar a ficha de observacao ou, pelo contnirio, preparar a ficha do doente, si 0 caso progredir para as formas contagiontes.

Dr. Ernesto Tomas Capurro (Argentina): Como delegado argentino adhierome a 10 propuesto por el Dr. Pesce en el sentido de que sin menoscabar la actividad de las instituciones particulares debe ser el gobierno el encargado de mantener el contrator de todo 10 ateniente con la lepra, sobre todo cuando como en la Argentina, el gobierno se mostr6 siempre intersado y mas en el momento actual en que hay in gentes esfuerzos por resolver ampliamente todos los problemas relacionados con la lepra.

Dr. Chaussinand (France): Je propose l'addition suivante aux conclusions de la Commission d'Epidemiologie: L'application des regles prophylactiques varie suivant les diverses regions. Dans les countrees a forte endemicite lepreuse, lorsque la segregation des malades est pratiquement impossible, Ie Congres recommande aux governements de ces pays de baser la lutte antilepreuse sur Ie dispensaire et la traitement libre.

Dr. A. Duren (Belgian Congo): (1) Medical Measures: Page 1, 6me ligne a parIes de la fur, icrire: "not more than 1000 patients." (2) Idem, page 2: Avants les mots "lepromin negative," fin du page, je propose d'ajanter: "La meilleure legra de conduite parait etre la suivante:"

Dr. Guillermo Munoz Rivas (Colombia): Se considera importante variar el termino "no infeccioso" por "probablemente no infeccioso."

[The various proposals which were made fell automatically when, at the end of the discussion, it was voted by a large majority that the report should be adopted as presented.]

{ SOCIAL WELF ARE*

Social assistance of the patient with leprosy and of his family is a fundamental necessity in combating this disease. Governments and voluntary organizations are therefore urged to accept responsibility for providing such assistance.

A "Social Assistance" program should include: (1) Provision of special institutions to enable healthy chil

dren of leprosy patients to live a normal active life, under the supervision of trained leprologists.

(2) Assistance of the families of leprosy patients to maintain their position in society without fear of ostracism.

(3) Provision of facilities for the education, occupation, recreation and devotional life of patients with leprosy.

(4) Assistance in the rehabilitation of those who are able to leave the leprosaria.

*The Committee on Social Welfare was composed as follows: Mrs. Eunice Weaver (Chairman), Dr. L. Rendon (Secretary), and Mr. P. Burgess, Dr. Contreras Duenas, Dr. N. D. Fraser, Mr. G. Greiffenstein, R. Ibarra Perez, Dr. E. R. Kellersberger, Sir Walter Kinnear, Dr. N. Olmos Castro, Dr. O. Orsini, Dr. M. Santos Silva, Dr. M. Such Sanchez, and Dr. R. M. Wilson.


(5) Health education, with particular reference to the leprosy problem.

ASISTENCIA SOCIAL*

La asistencia social al 'enfermo de lepra ya su familia constituye una necesidad fundamental en la lucha contra esta enfermedad.

Un programa de asistencia social debe incluir:

(1) La provision de instituciones especiales donde los hijos sanos de enfermos de lepra puedan llevar una vida act iva normal, bajo la supervision de leprologos entrenados;

(2) Asistencia a las familias de los enfermos de lepra para mantener su posicion en la sociedad sin temor al ostracismo;

(3) La provision de facilidades para la educacion, ocupacion, recreo y vida devocional de los enfermos;

-( 4) Asistencia en la rehabilitacion de los enfermos que pueden abande donar los leprosarios.

'r' THE WORDS "LEPER" AND "LEPROSY"t

It is agreed:

(1) That the use of the term "leper" in designation of the patient with leprosy be abandoned, and the person suffering from the disease be designated "leprosy patient."

(2) That the use of any term, in whatever language, which designates a "person suffering from leprosy" and , to which unpleasant associations are attached, should be discouraged. However, the use of the name "leprosy" should be retained as the scientific designation for the disease. Active steps should be taken to explain fully to the general public its real nature.

(3) That if the regional popular use of any less specific terms, in SUbstitution for the scientific name "leprosy," enables the general public to understand more fully and clearly the advances that have been made in the understanding, diagnosis and treatment of the disease, such terms may be used as suit-

* Spanish version of this item was prepared from the final English version by Dr. F. R. Tiant.

t The committee which dealt with this subject was composed as follows: Mr. P. Burgess ( Chai rman), Dr. E. R. Kellersberger (Secretary), and Dr s. J . Alexio, G. Clavero del Compo, N. D. Fraser, H. Gangerot, H. T. Kar sner, F. I. de Mello, R. Melsom, L. Rendon, M. H. Soule and J . Stancioli and Sr. Catherine Sullivan.


able opportunity offers; but it would be unwise to adopt such terms to conceal the true nature of the disease.

(4) That these conclusions should be communicated to scientific journals and the press.

LAS P ALABRAS "LEPRA" Y "LEPROSO"* J

Se acuerda: (1) Que el uso del termino "leproso" para designar al paci

ente de lepra sea abandonado y que la persona que padezca la enfermedad sea designada "enfermo de lepra".

(2) Que debe desaconsejarse el uso de cualquier termino, en cualquier idioma, que, al designar a la persona que sufre de lepra, lleve implicitas asociaciones desagradables. Sin embargo, el uso del nombre "lepra" debe conservarse como la denominaci6n cientifica de la enfermedad. Se deberan tomar medidas activas tendientes a explicar al publico, de una manera completa, su verdadera naturaleza.

(3) Que si el uso popular regional de terminos menos especificos en sustituci6n del nombre cientifico "lepra" permite al publico en general una comprension mas clara y completa de los adelantos que se han logrado en el conocimiento, el diagnostico y el tratamiento de la enfermedad, tales terminos pueden usarse en la oportunidad debida, pero nunea se adoptaran para ocultar la verdadera naturaleza de la afeccion.

( 4) Que estas conclusiones deben ser comunicadas a las publicaciones cientificas y a la prensa en general.

DISCUSSION

Dr. Froilano de Mello (Portugal): Las palabras tienen su psicologia. La palabra "lepra" es secular y no podemos cambiarla. Decir "enfermo de lepra" en vez de "leproso" vale la misma cosa. Debo informar que hay en portugues his palabras mas atenuadas "morfeico," "gafo," que pueden ser usadas para apartar del enfermo el senti do anetemico ligado a la designacion "leproso." Aplaudo pues, la 2a. proposicion del Comite. [Translated from the Portuguese by the Congress secretariat.]

Dr. Ernani Agricola (Brazil): No veo la necesidad de discutir el cambio de los terminos "lepra" y "leproso." Esto es una cuesti6n de educaci6n sanitaria y tambien de conseguir un tratamiento eficiente como en el caso de la sifilis. [Translated from the Portuguese by the Congress secreta ria t.]

*The Spanish version of. this item was prepared from the final English version by Dr. F. R. Tiant.

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